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• <br /> ApplicationforOnsite <br /> ppti For City Use Only: Date Stamp: <br /> 111111------ <br /> Wastewater Treatment System city of <br /> Date Received CV ',� <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DMSION Zoning by AUG Q 5 2024 <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 Receipt# MARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 BUILDING INSPECTION <br /> www.co.marion.orms/PW/BuildingInspection Activity# <br /> I <br /> ®s e_'- 0 ;„ 4 -_ A.Property Owner Information <br /> CA-I'V41 e Via-vh e4' 3 633 SE .2- - 'Ave Fi-r a4-.2.I, OR. e(7zo Z 5 13 - z .s= 1 - <br /> Name Mailing Address City, State,and Zip (Area Code)Phone e# <br /> . <br /> 0. B.Legal Property Description.- <br /> Legal Description Taxes Acrrage-er-Lot Size <br /> Subdivision Name Lot Block <br /> riii- ,lam, a:ii' bit SE S/titeA -1-0-)-) oIZ 47 3V <br /> Property Address I City /� J State/_ Zipi -Code <br /> Directions to Prope : S WA').01/1 . bc7% 'Zl-4 p-yt� ,- S';i U`���Fd� i I I. l/ J d- --I- (/' , CCU aS ) <br /> 6t z.o f 1e out{ across-fir-o-m 2(T( siIvor balks Jr:5 . -� yc t-.e Desc ,-i- .s- Lie, <br /> C.Existing Facility/Proposed Facility!Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ['Single Family Residence I1 Single Family Residence ['Public <br /> :3 Name <br /> Number of Bedrooms Number of Bedrooms IN.,Private <br /> 0 Other El Other Well,O Shared <br /> D.Type of Application <br /> igi Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> ❑ Other—Please Specify <br /> If the required fee and attachments are not included with this application, it will be returned to you as incomplete. <br /> Post the orange card at the entrance to the property. Flag the test holes. <br /> By my signature,I certify that the information I have furnished is correct,and hereby grant Marion County,authorized agent of the <br /> Department of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> efrhro 1.e, WoLnier c•03 — '2-35" —3S-t <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> ;6 33 SE 2 4i e Pcv-Lia,r� OP, a 70-62- <br /> Applicant's Mailing Address <br /> t t <br /> elite/4 044/N---a/AA-W,1 <br /> i / /7—di <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner ❑Authorized Representative 111 Authorization to Apply form Attached <br />