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I _ <br /> Application for Onsite City Use Only: Date Stamp: <br /> -==%- Wastewater Treatment System City of <br /> IIIIIII <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PW/Buildinglnsnection Activity# <br /> A.Property Owner Information <br /> tr <br /> t9ewe SCO �� - A'ig1'k 4_e__3 if ) �Jr`I/ ZAJS� r1Iil OW 97t3?2 503 <br /> Name V Mailing Address City, State, and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> p a.bp p $ L'11 oq3 v� i �0000 2. 00 <br /> Legal Description .! Tax Lot Acreage or Lot Size <br /> PP z03 - NB ADS-O <br /> Subdivision Name Lot Block <br /> Mk o Svorfiejc J-%/ s_ ‹Viielt 0 itQ g M?2 <br /> Property Address City State Zip Code <br /> Directions to Property: Pa r{Nh 6z2p S It Si runt/'k hoop li// h 2 h9ffe'i tip so vanii---4, <br /> C.Existing Facility/Proposed Facility/Water Information <br /> E sting Facility: Proposed Facility: Water Supply: <br /> of Single Family Residence ❑ Single Family Residence ❑Public <br /> 3 './- <br /> Name <br /> Number of Bedrooms Number of Bedrooms 'P Aid <br /> id <br /> ❑ Other [Other Slop -)4e-volixn, 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 /> ❑ Repair Permit ❑ P• ermit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major El Minor El E• xisting System Evaluation ❑ Personal Hardship <br /> 4 Alteration Pe Ni ' ❑ Record Review ❑ Temporary Housing <br /> ❑ Major Pi Minor El Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> El 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 /> &O f O e, 503 33'7 S37? A 1APPQewe <br /> cant's e-Please Pr' Legibly Applicant's Phone Number DE Lic.# (if aPPh )31/k $$44010g5 l-./J Si- liner Ok 178 ? <br /> Applicant's ling •ddress g4 '% ,5<-7- 2h23 <br /> Signature / Date: CCB# (if applicable) <br /> Applicant is the Owner El 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 />