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i <br /> , a 5-(23, 5-1-7 Li <br /> Application for Onsite For City Use Only: Date stamp: <br /> ! ij Wastewater Treatment System City of RECENED <br /> Date Received <br /> IIIII MARION COUNTY PUBLIC WORKS Received by JUL 07 2023 <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 �A�10� COUN <br /> (503)588-5147 Fax(503)588-7948 Receipt# BUIL.Dif�l I�e�pCTION <br /> www.co.marion.or.us/PW/BuildingInsnection Activity# <br /> ::._:...:. _: - -_... ,.,,,,_. . ..:.::.::_ A Pra 'e Owiter`Irifoiinatton - - <br /> D v4 L 4 32 31 WI-f- I e.b[:wr 5, 5'at e D 9 T5oz Sv3 670 q fr... <br /> Name MailingAddress City,State and Zi Area Code Phone# <br /> ::::...:...:.�..::_.:..._:. _:.. B.Le alWro a :D... .:-,-:. : <br /> - -----:.._. .:_._. ,_ esers ton_:=_�-;::t:.,::.::::.: :.::.=:.v::-:__:...; - -- - - - <br /> etcciA.A <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision� Name Lot Block ` <br /> " 3 I 114 1/6Axi ke - 'Cr Sil 9Z ?D <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> • <br /> >_s:= - :_CExisttngFaci(ity/_ProposedFaciilytWaterinfti6i-A oil-- -._:_•: <br /> Existing Facility: Proposed Facility: Water Supply: <br /> OSingle Family Residence ❑ Single F ily Res' nce 1 ❑Public <br /> 3 _ s Name <br /> eof BedroomsNu r Be oo , - p <br /> Number Number of dr ms ® Private 1/1/ <br /> ❑ Other gi Other � t4O d1 J Well,Spring,Shared <br /> _....»......, ..::.:::::....�D>:Type Qf:Appllcatton <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> El Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> 0 Major ❑ Minor ❑ Existing System Evaluation Personal Hardship <br /> / <br /> ;Alteration Permit ❑ Record Review 0 Temporary Housing <br /> 0 Major [j 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 /> Depa ent of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> V,A, $omits L nPI�13-Ict,-e*oy <br /> -eAA VIA fit,-mac, _ Sv) ` 31 ifif <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 73/ H - f4 s ri& A-V E SE .. 9(OM. t g. 91-306 <br /> Applicant's 'ling Address <br /> -2 % —2_3 //37d 1 <br /> Signature Dale: CCB# (if applicable) <br /> Applicant is the 0 Owner .p Authorized Representative ❑Authorization to Apply form Attached <br /> F:IFORMSISEPTICIS-01 ONSITE APPL JULY 2022.DOCX Rev 1/15,3/18,6/22 <br />