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.Zz_ aa ,/y _/-atl <br />Irr7,44.,.. Application for Onsite For City Use Only: 0. C <br /> cl,Date ,. <br /> ==- Wastewater Treatment System City of <br /> Date Received � ® n <br /> MI MARION COUNTY PUBLIC WORKS Received by ����,v� <br /> O 1JU � <br /> BUILDING INSPECTION DIVISION Zoning by 2}0 C <br /> 5155 Silverton Rd NE Fee (1)0es.,e cgl <br /> Salem OR 97305 it#p eceR n C TH <br /> (503)588-5147 Fax(503)588-7948 0 7; <br /> ww.co.marion.or.us/PW/Buildinnspection Activity# .-c <br /> w &I 60 <br /> A.Property Owner Information <br /> OPev Ocotr Comm Lug.ity PAYSDA 3Vt/ ruroea_ 1 oil- 9)0oz 503 697S'- g723 <br /> Name Ckuv eAn 6.6 ALLry r1,1/4 Mailing Address City, State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> Legal Description Tax Lot Acreage or Lot Size . <br /> Subdivision Name Lot Block <br /> aoto 7 /key 961 F (2u.rav-o. og_ 770a z_ <br /> Property Address City State Zip Code <br /> Directions to Property: Ju!-r 50ii.11-1 et <br /> Aks.Yove- , ©v. We51- 5 icl.a c21Fuh�E 91 E <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ['Single Family Residence 0 Single Family Residence ['Public <br /> Name <br /> • <br /> Number of Bedrooms Number of Bedrooms Cti41 Private <br /> `�] Other �`,1j AI r( $ Other dA�'luarci.. awl lawcgve. Well, pring,Shared <br /> D.Type of Application <br /> O Site Evaluation 0 Renewal Permit Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer 0 The Addition of One or More Bedrooms • <br /> 0 Major ❑ Minor 0 Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit 0 Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other . _ ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) - \\ \ <br /> �Other—Please Specify v�A� <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 /> <,y U)W iC95l.i l)�� 1oZWOO <br /> Applicant's Name—Please Print Legibly ` Applicant's Phone Number DEQ Lic.# (if applicable) <br /> toop., c, L/vy 17) CINAZY 42 9 Foy <br /> Applicant's �• .• 'I g Address <br /> s IV 9--7 7 <br /> Si:pa e Date: CCB# (if applicable) <br /> Applicant is the❑Owner 0 Authorized Representative 0 Authorization to Apply form Attached <br /> F:\FORMS\SEPTIC\S-01 ONSITE APPL JULY 2022.DOCX Rev 1/15,3/18,6/22 <br />