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Application for Onsite For City Use Only: Date Stamp: <br /> - Wastewater Treatment System City of <br /> — /J <br /> vA Date Received D �,©-E Ii \Y/ - <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by _ U FEB 08 2023 <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 Fee MARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 Receipt# BUILDING INSPECTION <br /> www.co.marion.or.us/PW/Buildin2Inspection Activity# <br /> A. Property Owner Information <br /> ZONJ\ \C <br /> Name 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 /> V?f L XP(NA+\I - -'-\\-X V <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 ❑ Single Family Residence ['Public <br /> 2 L\ Name Number of Bedrooms Number of Bedrooms IN Private V V`111v� <br /> ❑ Other 0 Other Well, Spring, Shared <br /> D.Type of Application <br /> 0 Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> IN Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> =r': Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> -;:t Major ❑ Minor ❑ Existing System Evaluation El Personal Hardship <br /> Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> Vi Major ❑ Minor El Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 0 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 /> App icant s Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> ?0 X StLk i vi rr €'v-, o(t.. ' 601 a <br /> Apj .cant' Mailing Address <br /> Ar"\ <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the El Owner ❑Authorized Representative 0 Authorization to Apply form Attached <br />