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, -S5- 2 Z-b l l 14 2-LP - P 0-11 <br /> .,, .,.,., Application for Onsite For City Use Only: I <br /> —=%�f� Wastewater Treatment System <br /> City of E C f n 7: <br /> MI <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by C LC 9 6 2021 <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee MARION COUNTY <br /> Salem OR97305 BUILDING IVSPECTION <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PW/Buildinainspection Activity# <br /> - = --_ �= _aL 'Ch�merInfomiahoII __ ..- -,- --� --- - -�. -= __s <br /> - - _ 1 <br /> ,�, )e /& �Wm1 `7 s--.il 11P z' Tl ,rr, /� '2 ' 75' <br /> Name Mailing Address 41,9-zo City,State,and Zip 3 Z Area Code)Phone# <br /> � <br /> rty t di <br /> , _ ,.B Legal a Descnp . ,- - - <br /> -... _� _ten_. .._-.� - S� a <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 9/1- 032 Gilif/ -5 77ilkh(f ©R___- 97 q-- <br /> Property Address City State Zip Code <br /> Directions to Property: ' <br /> i- .zi,;:, __ i ..._.. . a__.. cExisttngFifditity -PraposedFa lV4ter.Informahom _-_..___p'.., __ r;::: __._Ws �_... . <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ['Single Family Residence i:Ed Single Family Residence ['Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms Private <br /> ❑ Other ❑ Other Well pring,Shared <br /> .�t - 9.5�;._. --_,' , __;�.D :Type t� Ap ilcation�_g _ _ ---= ... v 5 <br /> ❑ Site Evaluation 0 Renewal Permit ❑Authorization Notice for: <br /> �®'Construction Permit El Permit Reinstatement El Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer 0 The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit 0 Record Review ❑ Temporary Housing <br /> ❑ Major 0 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 /> 4? as ,f�_ 42 -q f- 67095.E IVuIruc, <br /> Applic 's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> (75"--2.s- "-- 40 7 '','"-- s -21) 3 /e , / f)i1/D , r c)4- ?gag-2-- <br /> Appli is Mailin ddress <br /> /Z /6 2 Z <br /> Signs ` Date: CCB# (if applicable) <br /> .0/01,A,(L Z <br /> Applicant is the Owner ❑Authorized Representative El Authorization to Apply form Attached <br /> F:\FORMSISEPTI 1 ONSITE APPL]ULY 2022.DOCX Rev 1/15,3/18,622 <br />