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23 -o-v67 q5— PPM1 <br /> Application for Onsite For City Use Only: Date Stamp: <br /> .44 *,.144".-: City of <br /> - �� Wastewater Treatment System <br /> Date Received . <br /> IMOMARION COUNTY PUBLIC WORKS Received by D v E C [ V E <br /> BUILDING INSPECTION-DIVISION Zoning by <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 Fee AU6 0 9 2023 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> Activity MARION COUNTY <br /> A.Property Owner Information BUILDING INSPECTION <br /> Ad vJ tk i t cv Q.--A, ? ^ E3 t 1J0 _.c:?r ".1 . 2 .`3. r7—(al--.%Q <br /> Name Mailing Address - City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> 0 IR-`) U3 l O J) 1.. 12_C,J _5 29.1S6? <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> • <br /> (o 73(k , s tov, s,-.- _gc<_`::�.� 1— cl l 7 <br /> ? <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information • <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence Pf Single Family Residence ['Public <br /> Name <br /> Number of Bedrooms Number ofSedrooms .g Private 1,->P /l <br /> Other Ei Other Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit 0 Permit Transfer ❑ The Addition of One or More Bedrooms <br /> 0 Major ❑ Minor 0 Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review 0 Temporary Housing <br /> 0 Major 0 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 r 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 /> Lone Pine Corner Septics Inc. 503-873-7157 37003 R-I-100 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 8778 Cascade Hwy NE Silverton, OR 97381 <br /> Applicant's Mailing Address <br /> 40 J ( + 1 5 (1» -7-1 7 ,` 177063 <br /> Signature U"_ Date: CCB# (if applicable) <br /> Applicant is the 0 Owner 0 Authorized Representative [-Authorization to Apply form Attached <br />