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DocuSign Envelope ID:C34D94DB-F044-4F98-89A8-7595C0758123 <br /> aZ—cL tL 1i— PR-m-I <br /> i.! Application for Onsite ForCin Lisel3nly: <br /> City Date Stamp <br /> Wastewater Treatment System -� <br /> yy., Date Received D - C E [ NED <br /> r , 'a. MARION COUNTY PUBLIC WORKS Received by - -� <br /> BUILDING INSPECTION DIVISION Zoning by - DEC 19 2022 <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# - M;RION COUNTY <br /> www.co.Marion.or.us/PW/Buildinginspection Activity# BUILDING INSPECTION <br /> A.Property Owner Information <br /> D&D Frank Family LLC/Dennis Frank PO BOX 79 Mill City, OR 97360 503-931-4313 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> 0e2W130 9 t to <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name — Lot Block <br /> 8637 Silver Falls Hwy SE Aumsville OR 97325 <br /> Property Address City State Zip Code <br /> Directions to Property: Take Cordon Rd NE to OR-22 E in Salem(6.1rn1),Follow OR-22 E to OR-214 N.Take exit 7 from OR-22 E(2.6mi) <br /> Turn tell onto OR-214 N(1.0 rni)Your destination will be on the left <br /> C.Existing Facility/Proposed Facility I Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> gaSingle Family Residence ❑ Single Family Residence ❑Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms .121 Private <br /> ❑ Other ❑ Other 'pring,Shared <br /> D.Type of Application <br /> 0 Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit 0 Permit Reinstatement ❑ Replacing a Dwelling <br /> ® Repair Permit ❑ Permit Transfer 0 The Addition of One or More Bedrooms <br /> ® Major 0 Minor 0 Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit 0 Record Review ❑ Temporary Housing <br /> ❑ Major 0 Minor ❑ Other 0 Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 0 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 /> Best Septic Inc Rep Haylie Conley 541-484-0844 37467 <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (ifapplicable) <br /> PO BOX 40606 Eugene OR 97404 <br /> Applicant's Mailing Address -' <br /> 954,11 ee 09/20/22 _ 153656 <br /> Signatui yt Date: CCB rt (if applicable) <br /> Applicant is the 0 Owner 171 Authorized Representative ®Authorization to Apply form Attached <br /> 1'j IC. <br />