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Oa-ob3asc1. <br /> Application for Onsite <br /> .nfw,�� �� For City Use Only: Date Stamp: <br /> ��>- Wastewater Treatment System City of ER-FC-E1 V <br /> MIN <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by 9?i l 4 2022 <br /> 5155 Silverton Rd NE Fee MARION COUNTY <br /> Salem OR 97305 BUILDING INSPECTION <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PW/BuildinzInspection Activity# <br /> i +�-A. <br /> PPropOwner Information ♦� <br /> D 0Ip'N r1A_ PeiC lrS qqz VA Llerty J Np E 5 ievoi ORg731-7 <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> 072+43Zc7D00 i3Oc <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name / Lot Block <br /> qC/'Z .LVA L1J A)E. Se. levvn 012 97317 <br /> Property Address City State Zip Code <br /> Directions to Property: EAs 1 ®►l C c Airy- r S�-• -Cr v►, C'e.3Yel.Gv r-e c( 1-K I v- c.' _4.r„1 <br /> MeY1l, n14 JA I_ 1U -4-i, ge a oil e4yf S•etz oC /✓A 1n. <br /> C.Existing Facility/Propos'ed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> 0 Single Family Residence X.Single Family Residence ['Public <br /> 11 Name <br /> Number of Bedrooms Number of Bedrooms Private 1AJ r--1 I <br /> ❑ Other 0 Other Well,Spring,Shared <br /> --_1 _ D,Type of Application, <br /> b Site Evaluation ❑ Renewal Permit ❑&ythorization Notice for: <br /> P. Construction Permit ❑ Permit Reinstatement Qr]Replacing a Dwelling <br /> ElRepair Permit ❑ Permit Transfer U The Addition of One or More Bedrooms <br /> �,q ❑ Major ❑ Minor ❑ Existing System Evaluation El Personal Hardship <br /> �J Vration 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��pa� of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> V\eit% hoz - !$c. .503_C/32-4//7c 3.373/ <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 8 (-n 2 `<f g lack 1-‘a.vk C+- Sf St_levti OR 617317 <br /> / <br /> Applicant's Mailing Address <br /> � � � L L/ 2Z~ ZZ i C 56V8 <br /> Si re Date: CCB# (if applicable) <br /> Applicant is the 0 Owner Authorized Representative ,Authorization to Apply form Attached <br />