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<br /> 4, ,,,...„.. Application for Ors to For City Use Only: C Wastewater Treatment SY stem City ofIIIIIII—
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<br /> Date Received JUN MARION COUNTY PUBLIC WORKS Received by — UN 0 9 2023 .a_.
<br /> BUILDING INSPECTION DIVISION Zoning by - _ MARION COUNTY 5155 Silverton Rd NE Fee BUILDING INSPECTION
<br /> Salem OR 97305 •.
<br /> (503)588-5147 Fax(503)588-7948 Receipt#
<br /> www.co.marion.or.us/PW/Buildinglnspection Activity#
<br /> ,. x _ f. 4 .:, V; :4 .. _ I',PPP,rty4W407 ifQ tZorr
<br /> 5a e q..4_ u.11/4.,\\t, t,,511-t 4.91,,N1 13N�ti Sw M cYQ f 13,i 1 541 =9-1(-k411' f
<br /> Name Mailing Address City,State,and Zip (Area Code)Phone#
<br /> �$��.�#�,u-r'' �.e"F"`3 ,�,,a.+...a*��1 �x ism c� kx �� a�r �y�City,
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<br /> ER -u_IR- ��_ In '.'�iki-,... '`60114. }pe..rty'Descnptiotl 'a:.� s-i' e
<br /> Legal Description Tax Lot Acreage or Lot Size
<br /> Subdivision Name Lot Block •
<br /> Vt51L1 9-\915r,N3lbroo\t...Dr Sta .i.rn oz. °113\ 1
<br /> Property Address City • State Zip Code •
<br /> Directions to Property: ,
<br /> ` < - Z w EAErAt. a,C..EicrsS aj#iWi /;Proposed i64.*i.W atet InfO'M tafton_ ,. . . : i i,€ '
<br /> Existing Facility: Proposed Facility: Water Supply:
<br /> yiSinglejcily Residence ❑ Single Family Residence ❑Public
<br /> Name
<br /> Number of Bedrooms Number of Bedrooms Private \At,\'
<br /> ❑ Other El Other Well,Spring,Shared -.
<br /> :a ,a,-. r ,. z_...; k. -: , ' D,fiype;. f.t p 2 r-.ia.. �r-�.kn,w,. .�p- ..�s ._...:. ..�,..s?zve:� .:. ' -..�.'. 0�. p�1Cdt'rQn- ;��;� ... - ..=�55'i"a.H
<br /> ❑_Site Evaluation 0 Renewal Permit ['Authorization Notice for: •
<br /> ❑ Construction Permit 0 Permit Reinstatement 0 Replacing a Dwelling
<br /> [q] Repair Permit 0 Permit Transfer • 0 The Addition of One or More Bedrooms
<br /> ❑ Major 5j Minor ❑ Existing System Evaluation 0 Personal Hardship
<br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing
<br /> ❑ Major 0 Minor ❑ Other ❑. Connecting to an Existing System Never in[Ise
<br /> (over 5-yrs o.d)
<br /> ❑ Other—Please Specify
<br /> ' If the required fee and attachments are not included with this application,it will he 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 Marian County,authorized agent of the
<br /> Department of Environmental Quality,permission to enter onto the above described property for :he sole purpose of this application.
<br /> Vst(-e 50, \c_ 53-Y13- 1033 33b 13
<br /> Applicant's Name—Please Print Legibly Applicant's Phone Number - DEQ Lic.# (if applicable)
<br /> P0. °I I77 g it C p k OR. 720 S
<br /> Ap..icant's Mailing dress - -
<br /> I • (9 i i 7:5 Cn°1 i 5
<br /> Si•nature Date: CCB# (if applicable)
<br /> Applicant is the 0 Owner M Authorized Representative Q�Authorization to Apply form Attached
<br /> F:\FORMS1SEPTIC\S-01 ONSITE APPI.SEPT 2022.DOCX Rev 1/15,3/18,6/22 •
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