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56 3- Z 3— OO Lt 1jt,- ) 1J Q <br /> Application for Onsite For City Use Only: Date Stamp: <br /> �L Wastewater Treatment System City of <br /> NW Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> H-ECEIVE7 <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/PWBuildinitInspection Activity# BUILDING? INSPECTION <br /> ._ _w._. , _ __ _ ,,w. -�.�.A Property,OwnerInformatto._ r _,,,,,2 _ _ _ ,. :_ _ _ ,_vv-u__, <br /> C; J1COS P.a. Box2.� I� S6 - - o <br /> S �. >r V t� 0 1 Q 7�.9 3� <br /> A EtZ, 8 �i� N R q �a q <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Leg'lO 1 peaty Description ....�__u,. .� .� .<v. <br /> Legal Description Tax Lot Acreage or Lot Size <br /> CIA*O041 NA\LLS WJ. e- POAC 1. I. <br /> Subdivision Name Lot Block <br /> il 05 Piltt&S \ GAP M. S , liUt1.1.1E2 OPT cr./Ill- <br /> Property Address City State Zip Code <br /> Directions to Property: NC-pf t Cs ILNE ft_ OF 1-1U NS0 KSIZ- 20 SE t. igtr 1S \ GAP RD. S- <br /> i <br /> ` v _ n_. C Exisring Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Single Family Residence 0 Single Family Residence ❑Public <br /> 1 '3 Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> ❑ Other 0 Other Well,Spring,Shared <br /> r_ __ r.u�� n_�� .a__.___, _ .. .a_ w ... , . D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> El Construction Permit El Permit Reinstatement El Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer El The Addition of One or More Bedrooms <br /> 0 Major ❑ Minor 0 Existing System Evaluation El Personal Hardship <br /> ❑ Alteration Permit g Record Review SC p El Temporary Housing <br /> El Major El Minor ❑ Other El Connecting to an Existing System Never in Use <br /> • (over 5-yrs old) <br /> El 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 /> I 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 /> M, SEtI-V'C(S So3-1z-q-3(,00q <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> P.O , gbk .)-81211- wRt--Si►i-muE IOR et101 a <br /> A ' ant's Ma' ' Address <br /> Si 5\1-3 <br /> Signature Date': CCB# (if applicable) <br /> Applicant is the g Owner ❑Authorized Representative El Authorization to Apply form Attached <br /> F:\FORMS\SEPTIC\S-01 ONSITE APPL SEPT 2022.DOCX Rev 1/15,3/18,6/22 <br />