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a-3-bk 10-C\ <br /> Application for Onsite For City Use Only: Date Stamp: <br /> uni_--------,--. "�- Wastewater Treatment System city of —, <br /> Date Received <br /> ® E C L U \( i <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by EEC 27 2022 r� <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 iviARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 Receipt# BUILD NG INSPECTION <br /> www.co.marion.or.us/PWB Sl uildinnspection Activity# <br /> te..___ .......•_._-...i:v:.S_::.._...,-�::-::.r:,.C-__,::.r:!.r_.:c_.::_:'::_.:-_-.::_._--_:_-:::_:_a:..__...._.._.-:!::::u:- ::- ,....I.I.. __.i..v_._._..__ _ ___ <br /> 9,, IA - <br /> .) IN./a- ( ivai--7-,se P-P21,J 3 ccivs f7giz-eg /44001-__ •7z 5--a3, yis2— g-9F-- <br /> Name Mailing Address City,State,and Zip (Area Code)PhoPhone# <br /> ._.__...r...._..:..._..._..-....u....._..........._,.,.,....,,:.,...,,,.,.....�._.._......._,:_._....._............._�._F�l_._.._�:...:..-.-, .._. LLB.__..._....._.._....:..._.___._. __- ___ <br /> ME <br /> c5A1U.)t DOuo0 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> • <br /> Subdivision Name Lot Block <br /> a2g L-69 14g''"'" " r 5 r-q., ep/t/ 74 a/WA- <br /> 8, T7602___ <br /> Property Address � City State Zip Code <br /> Directions to Property: <br /> R_ I _ __ . _ ____ . ....:..�.,...:..:.............._,..-.. ...._..:....: W iii a W ti riAg I�a�. , .! _ a . - -.I:. <br /> - _ <br /> k : - <br /> Existing Facility: <br /> Proposed Facility: Water Supply: <br /> 0 Single Fa 'ly Residence ❑ Single Family Residence ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms <br /> Private <br /> Alak <br /> ❑ Other <br /> _ ....... <br /> ___ _❑ Oth er <br /> .pr ing, Shared •}-_ _ �:- _ —_ nv _ nfw —E I S __ = _L=_:__ _ <br /> ,_ <br /> — <br /> Site Evaluation. ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms •• <br /> It_ <br /> ❑ 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 5-yrs old) <br /> ❑ Other-Please Specify <br /> If the required fee and attachments are not included with this application, itwill 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 /> DepartmentDe of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> \1Q /bAI A-Cl Od 503 - yes%,W,/2 - 3q('b <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> P6' C&X /1,2 7 /,�t4�4- oe 9?o > <br /> Applicant's ailing Address ( <br /> Si` e Date: CCB# (if applicable) <br /> i <br /> Applicant is the❑Owner thuorized 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 />