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i -bv 2)°►5J <br /> , ,,.„, Application for Onsite For City Use Only: 1 b"&eEI v <br /> -� Wastewater Treatment System City of Mill �1(4 <br /> ����J� Date Received MAY 0 4 2022 <br /> MARION COUNTY PUBLIC WORKS Received by -Received <br /> COUNTY <br /> BUILDING INSPECTION DIVISION Zoning by BUILDING INSPECTION <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 ?_ i ' O i s <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PW/BuildingInspection Activity# <br /> i _u A. roperty Owner Information '_.. ....._ g' __. .,_ .._ __. , _._... <br /> 1. e'1 L2 re-V ) 1233 —° E,vc T2.! J•lv,ei--5 .Or 9 9_° '` ,.5 '.3-2'23-6,--7,e7`! <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> Legal Fiojertytesenptiort <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> -5-1 546_,r-44- <br /> Property Addres City State Zip Code <br /> Directions to Property: <br /> _ C V:Wgtf.4a Yg:4osedFacVty/ gterTnfarmatl*':r_..,s . li .... .._ _. ,}.. <br /> Existing Facility: Proposed Facility: Water Supply: <br /> 0 Single Family Residence ® Single Family Residence ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms El Private e,S e� c- <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> B _ ._ ._ .. i. .2 .. 4 _ED Type of ipplacatioxr w n _ .._.. . F.- ...._ .... ._ wA.g k. _.... TM <br /> L; Site Evaluation 0 Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit 0 Permit Reinstatement ❑ Replacing a Dwelling <br /> 0 Repair Permit 0 Permit Transfer 0 T• he Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor 0 Existing System Evaluation ❑ P• ersonal Hardship <br /> Al-ration Permit ❑ Record Review 0 Temporary Housing <br /> ►r! Major 0 Minor 0 Other 0 Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> ❑ O• ther-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 /> f1(g-rl I-41/ /so --C o '--73- 7i 5 % .. 3 71-7� <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 0--77r- /i-4f--S c /// c A.'''...."�` S,/v�r—:�� ccr-e._ > %% ./ <br /> Applicant's Mailing Address <br /> 1410.-QA,tt C. tAf.k3A011 6L xl,zb--A <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> G:WORMSISEPTIC\S-01 ONSITE APPL SEPT 2018.DOCX Rev 1/15,3/18 <br />