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SS5-2_3 - ODLt13( —EVkL <br /> ,;, ,,„,4 Application for Onsite For City Use Only: Date Stamp: <br /> : Wastewater Treatment System City of <br /> MI Date Received HEC -EO <br /> YE7 <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by --../ <br /> 5155 Silverton Rd NE Fee MAY 16 2023 <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# MARION COUNTY <br /> www.co.marion.or.us/PW/BuildingInsnection Activity# BUILD NG INSPECTION <br /> ,._.,...A,,PEoperty Owner Information <br /> AC,SSttvAC S PG. Box, 428%'L U.ALStt%JvlwEloA °no'to 533-1 - —3(Qo•\ <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> .. •_ r_ ._.. • <br /> B Legal Property_Description w.._._.__.w._. <br /> O°j7.wil0000101 -.a_.Ac-(i Sv <br /> Legal Description Tax Lot Acreage or Lot Size <br /> SN,pc ay.) NtuS No, '2- PP2CEl_ 'L <br /> Subdivision Name Lot Block <br /> \1105 PPnc-ts\p‘ G,/►P ALL S. TutiNEn_ oR ern ell-- <br /> Property Address City State Zip Code <br /> Directions to Property: NEA&GOR.NE2 of gut-ISAKER RD. SE F PPRRksv\ GAP RP. S. <br /> ._.._•a , L._:. ,.�__.,,,,_, �_:_.�__ _C Existing Facility_/,Proposed Facility I Water Information„._ �___;.__..e.,____ _, _k _,:_., <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ['Single Family Residence rg. Single Family Residence ❑P_ublic <br /> 4 Name <br /> Number of Bedrooms Number of Bedrooms 0 Private <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> 4 7T ,._ __ . 1-__ . ;` _.w. w- ,L, __D .TypeofApplhcation_2 w w�__ _ w.._ u.:,.� ._.,..w:r.s_ _- ._- <br /> N <br /> Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> Construction Permit ❑ Permit Reinstatement ❑ 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 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 /> C, SG/41MS 563 12-9-3(069 A <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 17,0. 8o)c 14302 1 tAtt-S'ikovtitd.E i aR all°, 6 ip <br /> nAp ' is MaAddress <br /> /Signature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner 0 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 />