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GI'Or0i(e& s f 4,X4-r <br /> Atieb,N, Application for Onsite For City Use Only: V 7Wastewater Treatment System city of C E <br /> t I a--m.—......--4 Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> MAR 01 2024 <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee MARION COUNTY <br /> Salem OR97305 Receipt# BUILDING INSPECTION <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/BuildingInspection Activity# <br /> !; P <br /> A.Property Owner Information <br /> R°9116N .Sc'1l4e - //567 48 10A- (% (24) ,5 r ta't f�P_77,0f so.�-T7I-7 (0 <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 /> ,SPC7 /fig/V 4 AfM e'o. Ali, , Lil�i -Jc 0P 77-s0 f <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 /> [1SingleFamily Residence 0 Single Family Residence ❑Public <br /> 3 Name/ 1 <br /> Number of Bedrooms Number of Bedrooms Q.Private awl µ{—'/ <br /> 0 Other 0 Other (10,Spring, Shared <br /> D..Type of Application <br /> El Site Evaluation El Renewal Permit ❑Authorization Notice for: <br /> El Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> El Major fl Minor ❑ Existing System Evaluation El Personal Hardship <br /> El Alteration Permit ❑ Record Review El Temporary Housing <br /> ❑ Major El Minor El Other El 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 /> Applicant's Name—Please Print Legibly Applicant's Phone Number a/ DEQ Lic.# (if applicable) <br /> 6 77/ tic ,l 2 (28ct7 Air M-5-es� $0,2- 77 JZ S— <br /> Applicant's Mailing Address <br /> 2/28/2 r 72037 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner Authorized Representative ❑Authorization to Apply form Attached <br />