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05-mg-15 <br /> 1 <br /> 4,4„ , Application for Onsite For City Use O ly: Dote sue: <br /> l _ Wastewater Treatment System City of <br /> Date Received D V <br /> 1 NM <br /> MARION COUNTY PUBLIC WORKS Received by <br /> E 0 <br /> BUILDING INSPECTION DIVISION Zoning byLi 5155 Silverton Rd NE OCT 18 2023 <br /> Fee <br /> Salem OR 97305 Receipt# MARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 Activity# BUILDING INSPECTIONwww.co,marion.or.usiPW/Buildiuejnsnectioa <br /> r� <br /> A. Property Owner Information <br /> `awns-t gw-4,�p ,QGSA.( l c C4-ee & l Sri" S?jaz4 -.-% it/Z. 9 g3g'( <br /> Name / Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> C1 1&>I t3GC,rs ICE) {C)C) i(3.-tT <br /> Legal Description ,� Tax Lot Acreage or Lot Size <br /> ! Gceck? PavGe t <br /> Subdivision Name Lot Block <br /> Property Address City State Zip Code <br /> 1 Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence ® Single Family Residence ❑Public <br /> L( !"' . Name <br /> Number of Bedrooms Number of Bedrooms a§ Private i,4}e(( "p-er uo,( <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D.Type of Application <br /> 21 Site Evaluation ❑ Renewal Permit DAuthorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit 0 Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> 0 Major ❑ Minor ❑ Other 0 Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> X -I•- Ce rt wu c. c,►at S{ . t4,4S4 9'.Cv',4r fs ❑ 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 /> Oregon Sewer&Drain LLC 503-874-9414 38968 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> PO Box 1282 Silverton, OR 97381 <br /> Applicant's Mail' d <br /> 't-, b2-2,`3 201683 <br /> tore Date: CCB# (if applicable) <br /> Applicant is the❑Owner ' Authorized Representative Authorization to Apply form Attached <br /> ' 5-oba <br />