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023 '3( )a 5 <br /> Application for Onsite <br /> :.,� b• ,,;! pp For City Use Only: Date Stamp: <br /> --- :�-7 Wastewater Treatment System City of <br /> Date Received s <br /> Received byR <br /> E C I �E� <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION Zoning by ii I Ip� <br /> 5155 Silverton Rd NE Fee JUId , 02023 <br /> Salem OR 97305 <br /> #Receipt �i ,/ <br /> (503)588-5147 Fax(503)588-7948 MARION COC�'.�.• <br /> www.co.marion.or.us/PW/BuildineInsnection Activity# BUILDING INSPEC iON <br /> =w„€ji .uz , , ., .l_ property©caner Infarmatla .,=,.,, zi.t., �. .. <br /> fA ► Lf127a. Pvtall 22V,I igI life get £f_ givz / <br /> 0A T 7/37 '' <br /> Name Mailing Address City,State,and Zip (Area Code)yhone# <br /> 25: : n w. 7 a.. - B Legal Property Description ` . i <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> a61-'74/ a i trf 54, P,Q Uz v R__, <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> z..._. ..i _, ,, _...._. 'S,CS.Exist�ug Faoil#y/Pr ose'd acFacF ility f Water lnfaiinatlon -:: . ,_._._ __ ,..._ _ .___.__i <br /> Existing Facility: Proposed Facility: Water Supply: <br /> 'Single FamilyFamily Residence %Single Family Residence ['Public <br /> 0 Name <br /> Number of Bedrooms Number of Bedroomsrivate Alli <br /> ❑ Other ❑ Other Well, .ring,Shared <br /> D Type of Apphcatton <br /> ❑ Site Evaluation ❑ Renewal Permit Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement Z,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 I have furnished is correct,and hereby grant Marion County,authorized agent of the <br /> Department of,Eyv rqn a tal ual `tfT�!°Iis iign o e ter onto the above described property for the sole purpose of this application. <br /> Pit I�u� - 5o3-56-q- L60e <br /> Applicant's Name—Please Print Le bly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 1elI3) R ilrcA2 get k)- 54-. PA-L_ , O2 C( 703"7 <br /> Ap licant's Mailing Addr s <br /> << , toy / 3— , -3 / .P-S63ct <br /> ignature i Date: CCB# (if applicable) <br /> Applicant is the❑Owner ra Authorized Representative ❑Authorization to Apply form Attached <br /> F:\FORMS\SEPTIC\S-01 ONSITE APPL SEPT 2022.DOCX Rev 1/15,3/18,6/22 <br />