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Application for Onsite For City Use Only: 4 j�-��DDate Stamp: <br /> �w Wastewater Treatment System City of:MI <br /> RECEIVED <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by FEE) 212024 <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PW/BuildingInspection Activity# <br /> _..: .._....._ : _.:: _.__... A Property OwnerInfomiation <br /> Zac,\,i c&ci 'tov ety I3283 P.Lcsa 14\ 3E Twc,nef 10 R 113/2 503-507-45't( <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> ' B Legal PropertyDescnQt on.-----=—.._:.... _.._ ._..._ �, _.. _._.__:_ ._.::. -- --t <br /> 2.7 N <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 13287 P;co, e, Vl.sE - Tint rGr p_ _ 11312 <br /> 2 <br /> Property Address City State Zip Code <br /> Directions to Property: Locaktek c\A- 132.93 9c c►. c P1. sE 1Tu,.cn q <br /> et I 0 it 73 et Z. <br /> 1 5 ecoetski Wc.S pask:wn. ovkea av :S fie.. E0.5k - - <br /> 'Qot .oh <br /> n C Existing Facility/,Proposed Facility OVater Information' <br /> Existing Facility: Proyosed Facility: Water Supply: <br /> 0 Single Family Residence pf Single Family Residence ❑Public - <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms Se Private WeA <br /> ❑ Other 0 Other Well, Spring, Shared <br /> _-_ __.. '_..__D Type ofApphcation.,..__-. °.__ _... ___... _.�___... _ _s <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 /> Department of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> Zo►chcacy 0v e.Y 503 -507-4SL b JO/A <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if pplicable) <br /> 132-93 `P:cascei. w% s a 1 TaoCvtec 1 c7R 1973Sz <br /> Applicant's Mailing Address <br /> fki A <br /> ignature Date: CCB# (if a plicable) <br /> Applicant is the❑Owner ❑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 />