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Application for Onsite For City Use Only: D e <br /> City of <br /> — Cl <br /> = 17 Wastewater Treatment System ' K <br /> no_. Date Received , > lid <br /> MARION COUNTY PUBLIC WORKS <br /> Received by I7 C 0 <br /> BUILDING INSPECTION DIVISION Zoning by -)5 r- <br /> 5155 Silverton Rd NE ' °� I-lid <br /> Fee 1`r ,� J <br /> Salem OR 97305 �, <br /> (503)588-5147 Fax(503)588-7948 Receipt# 0 ® Q <br /> !TIC ry <br /> www.co.marion.or.us/PW/Buildinglnspection Activity# ( 7 N .-- <br /> A Property Owner Inforniatlon `� <br /> h4g5.,V. kbiy to & (596 d, - DE 9JJ Same Address Ci State,and (Area Code)Phone# <br /> N Mailing _. City, Zip <br /> , B.Legal Property Description- �q <br /> Cam., 8� <br /> Legal Description Tax Lot Acreage or Lot Size <br /> l .efad 6, Cl,�°..5 <br /> Subdivision Name Lot Block <br /> - � � 7 ,-1 A/ `� ,�yO�s A 0 . 993,r? . <br /> Property Address / City State Zip Code <br /> Directions to Property: /Y Ay .2 f5,7 7 cc�.✓V „41'1' �/ <br /> . .:: . . , .. C Doting Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence ❑ Single Family Residence ❑Public <br /> Name x" <br /> Number of Bedrooms Number of Bedrooms 0 Private <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D' Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit 0 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 0 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 /> A-4/ ./47 E'/�- s -3, /-v2Sl�....3ppant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> to , /2g 5 Xyo i Ooe 9jj <br /> Ap h s Mailn A dress / <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the Owner CIAuthorized Representative ❑Authorization to Apply form Attached <br /> F:\FORMS\SEPTI -01 ONSITE APPL SEPT 2022.DOCX Rev 1/15,3/18,6/22 <br />