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Application for Onsite For City Use Only: Date Stamp: <br /> ���irmili Wastewater Treatment System City of <br /> Date Received A 5CEINED <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by _ I FEB 08 2023 <br /> 5155 Silverton Rd NE <br /> Fee <br /> Salem OR 97305 MARION COUNTY <br /> .� (503)588-5147 Fax(503)588-7948 Receipt#_ BUILDING INSPECTION <br /> ww .co.marion.or.us/PWBuildindnsnection Activity# <br /> w <br /> _ A Property Owner Information <br /> ZthIP4‘16. -111*." <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 /> 1 Av+ �rO�,u� .r1mm ty - <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C.Existing-Faaih <br /> h!t:Pro Posed Facility I Water-Information ;: , <br /> Existing Facility: Proposed Facility: Water Supply: <br /> I{Single Family Residence .0 Single Family Residence ❑Public <br /> 2 _t•I Name <br /> Number of Bedrooms Number of Bedrooms 151 Private Vl`QA <br /> I ; <br /> 0 Other 0 Other Well,Spring,Shared <br /> q ype;of'Application <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit 0 Permit Reinstatement 0 Replacing a Dwelling <br /> -`ii Repair Permit 0 Permit Transfer ❑ The Addition of One or More Bedrooms <br /> -111 Major 0 Minor 0 Existing System Evaluation 0 Personal Hardship <br /> Alteration Permit 0 Record Review 0 Temporary Horsing <br /> Major ❑ Minor 0 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 /> Applicant s Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> "�� 2t1 OQ ---aid r\eArl oft o1�l 'P a <br /> A can' Mailing Address <br /> Signature 1 Date: CCB# (if applicable) <br /> Applicant is the 0 Owner 0 Authorized Representative ❑Authorization to Apply form Attached <br />