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tby6e- Ai4-//- <br /> /Application for Onsite For City Use Only: Date Stamp: <br /> %;;=_-" Wastewater Treatment System City of <br /> iiiii. <br /> Date Received , L3 ' <br /> Co <br /> MARION COUNTY PUBLIC WORKS Received by c <br /> BUILDING INSPECTION DIVISION Zoning by F IM <br /> 5155 Silverton Rd NE Fee z T_ C <br /> Salem OR 97305 0# z <br /> (503)588-5147 Fax(503)588-7948 Receipt0 c 0 <br /> to <br /> www.co.marion.or.us/PW/Buildin:dnspection Activity# _ p o <br /> z Iv <br /> A.Property Owner Information <br /> {'J <br /> C•ell it CatiQle ( t4al5 tUa►ht 1I-Atgd.S\' SO‘ARMA, R( Cfl' 2 z <br /> Name Mailing Address City, State`and Zip (Area Code)�� <br /> B.Legal Property Description <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 4215 Ctovearrj ke, ' S IVYNtif ( YZ Ci 7 3012 <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 0 Single Famil Residence ['Public " <br /> J Name <br /> Number of Bedrooms Number of edrooms 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 ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> El Repair Permit ❑ Permit Transfer El The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor El Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review El Temporary Housing <br /> ❑ Major El Minor ❑ Other El 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 /> btf GW1MY1 503 -30q—bvtLi1 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> S' M VY1,fAra(\ Ir\4 iL ( -d- SE i VV IMAr( O-(Z R13O 2. <br /> Applicant's Mailing Address 'J� <br /> lip • tomm.- <br /> 1111`�ii) <br /> Signa �� Date: CCB# (if applicable) <br /> Applicant is the❑Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> F:\FORMS\SEPTIC\S-01 ONSITE APPL JULY 2022.DOCX Rev 1/15,3/18,6/22 <br />