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01)—W5C)k 73-1 <br /> r-� p� p, <br /> °` Applicationfor V Onsite For City tire:°My: L E C E� M E 1 <br /> WastewaterTreatment System ciy�f <br /> Dam RecvedJUL 3 0 2024 <br /> MARION Ct tiNTYPU.BL1C WORKS Reethed'by . <br /> DUI".DLNG 1 N PEC'rtoN DIVISION busing by <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 <br /> (503)583-5147 Fax(503)538 7948 <br /> www.co.marion:or,us/PW/Bnildint:Inspectiott Activity <br /> A.Property Owner Information <br /> r L`e,�` •:fir- to tiox 2L( r fv c' -- ?,? <br /> ed- <br /> Nance Mailing:Address 'City,State,and Zip (Arca Co* <br /> B.Legal•Property Description . <br /> Legal Desctiption. Tax Lot Acreage or Lot S <br /> de <br /> • <br /> Subdivision Name , Lot Block <br /> 2.t0 - <br /> Property Address City State Zip Co <br /> Directions to Property: <br /> i <br /> <; C.Existing Facility(Proposed Facility/Water information <br /> Existing Facility: <br /> Proposed;Facility Water Supply: <br /> USingle <br /> Residence... XSmgieFamily:Residence bhc t t <br /> Number of Bedrooms <br /> - Number of Bedrooms Private <br /> ❑,Other (3ther. g, <br /> :D,:Type ofAgPlication �. , <br /> ,Well;Spring, < <br /> J <br /> SC, <br /> Renewal Permit ❑Aathor zation.Notice for <br /> Site Evaluation 0 _ <br /> Construction Permit 0 PernutReinstatement ❑.Replacmg aDwelling <br /> RepairPerrnit ❑ Permit Transfer ❑:The Addition of One orNfore Bedr <br /> Major ;❑ Minor a Existing System Evaluation Personal.'Hardship <br /> Alteration Permit ❑ Record Review •. o;Temporary Housing • ' y <br /> to=Existin S mI�.Cann <br /> []-IvIajoz � Minor ❑ Other. Connecting qq <br /> []:Other—Please Specify <br /> If the required ee and attachments are not included with this application it will'be returned to you as incanVeto. <br /> Post the orange^rxrd at the entrance to the property. Flag the test,holes <br /> By ray signature,I"certify!that the information I have furnished;is correct,and hereby grantManon County,.authorized <br /> Department of Environmental Quality,permission to enter onto e above described property for the sole slime of tit <br /> " <br /> Applicant's Name-Please Print Legibly Applicants Phone Number DEQ Lmc.# (if applicable) <br /> . <br /> . 1)0 14n „7 W <br /> cling Address <br /> SAP s <br /> A Z <br /> IUate,7 CCB fr (£ap h le) <br />