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--- 47/r/2— —*/744j <br /> , � . Application for Onsite City Use <br /> y. u Date <br /> •,, For Ci Onl lW :� <br /> ���: City of <br /> _-- Wastewater Treatment System Date Received <br /> o <br /> D v <br /> IIIIII n <br /> MARION COUNTY PUBLIC WORKS Received by O C, <br /> Z. <br /> BUILDING INSPECTION DIVISION Zoning by O-) <br /> 5155 Silverton Rd NE Fee CI) O' - <br /> Salem OR 97305 Receipt# �' 1, (1 <br /> (503)588-5147 Fax(503)588-7948 0 <br /> ww.co.marion.or.us/PW/Buildin2lnspection Activity# <br /> w --.4.- GO <br /> O <br /> A.Property Owner Information 2 <br /> OQ— Door Comm tug'i4 Po:3o,x 3t/`/ I'}urov-r&. 1 c - 17oot 503 6978-g723 <br /> Name Chv,vc 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 /> aolv87 My 9' F Nt.,Lre'r� Of-- 77Oo Z.- <br /> Property Address City State Zip Code <br /> Directions to Property: Ss-r SC4,dn A,( F}-tx.YC�� r ors [,t)P5T- 5;at 2, /.(wy 99 6 <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> 0 Single Family Residence ❑ Single Family Residence ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms CVI Private <br /> V] Other �u r6 $ Other Chu v'tt•. uv� Cb�yCQv2 Well, pring, Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit lalAuthorization Notice for: <br /> ❑ Construction Permit ❑ 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 ❑ Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> (over Pr old) \ <br /> f�Other-Please Specify 0�01f.�. <br /> If the required fee and attachments are not included with this application, it willil -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 /> 1--.0-..ii I/0\Pt16- tc7b #1 -3 7 _o?(16U <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> (v(t Cr 11)L/ I7v Cray t 9?di3 <br /> Ap licant's ing Address ,tv 9-74_7 z, <br /> i e 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 />