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Z3- opi3-- --/Li_ P 'n')T <br /> .„, „,,,, Application for Onsite For City Use Only: Date Stamp: <br /> -—%---0 Wastewater Treatment System city of <br /> tili <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by n <br /> IJ <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 1. 2023 <br /> (503)588-5147 Fax(503)588-7948 Receipt# JUL <br /> www.co.marion.or.us/PW/Buildinenspection Activity# BUILDI� ARIONNU <br /> 1NSPEC�ION <br /> COU f�ITY <br /> A Property Owner Information <br /> iC �!i /� <br /> A. LAt � 256 ('®l ,mac f �. N , Kt'm- Off. (5 ) - &I <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B Legal Property Description <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> l350 (A CM0,ukta_ Rd- Al• / 5 i 2- fZ., og_ 97303 -((4f 3 <br /> Property Address City State Zip Code <br /> Directions to Property: ' <br /> C.Existmg Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ]Single Family Residence 0 Single Family Residence ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms 0 Private <br /> ❑ Other 0 Other Well,Spring, Shared <br /> D.Type of Application <br /> ❑ 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 /> 1D/epartmejnt� o <br /> of Environmental Quality,� pee�r`/issio//n/�to enter onto the <br /> .��above described� property for the sole purpose of this application. <br /> Applicant's Name—Please Print Legibly Applicant s Phone Number DEQ Lic.# (if applicable) <br /> ili0 Clip w� RC(. M , �EI2 g. 0R,, 6173°3 - 6/ 3 <br /> Applicant's Mailing Address <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the-XOwner ❑Authorized Representative ❑Authorization to Apply form Attached - <br /> F:\FORMS\SEPTIC\S-01 ONSITE APPL JULY 2022.DOCX Rev 1/15,3/18,6/22 <br />