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di-1 - c5b61,56 <br /> ,.4. ..,, Application for Onsite For City Ilse Only: ��,,op <br /> mii <br /> r=..:�< Wastewater Treatment System City of itECEBVED <br /> Date Received <br /> • <br /> MARION COUNTY PUBLIC WORKS Received by JUL 05 2024 <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Merton Rd NE Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588--7948 Receipt# <br /> www,co.marton.or, 'WBuildtnpjnaoeetlon ActivitY# <br /> A.Property Owner Information <br /> Karen Garcia 2y76 42hd Avg 56 591i1 OP 973)7 5-43-yz9-o9n2, <br /> Name Mailing Address , City,State,and Zip (Area Code)Phone# <br /> OA Z.W j YD oo7-900 B. <br /> Legal <br /> Property47P 2.04 D <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name yla Lot Block <br /> 24/7d � 5Citifrk, � 973f7 <br /> Property Address / City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility I Proposed Faeilrty/Water Information <br /> g Facility: Proposed Facility: Water Supply: <br /> CB u*Family Residence 0 Single Family Residence ❑Public <br /> 5. �/ Name <br /> Number ofBcdrooms Number ofBedmomn !La' M <br /> ❑ Ot1er El Other 0Spring,Shared <br /> D.Type of Application <br /> �O Site Evaluation 0 Renewal Permit [(Authorization Notice for: <br /> onstruction Permit 0 Permit Reinstatement 0 Replacing a Dwelling <br /> tit R_gair Permit,,_,/ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> Malmo CJ Minor DI Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit 0 Record Review 0 Temporary Housing <br /> 0 Major 0 Minor 0 Other 0 Connecting to an Existing System Never in Use <br /> l /4/f a 5 (,j (over 5-yrs old) <br /> I ❑ Other—Please Specify <br /> If the required fee and attacknenfs 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 /> :3—LC5 gest4Mq 5.© -- q32-viol 1132-3 <br /> Applicant's Name—Please Print Legibl f Applicant's Phone Number DEQ Lie.# (if applicable) <br /> Acp; if V,'a /i // 3dY /rc ;r /4jqça Sg S,/m,,, of? ql3ji <br /> Applicants g / <br /> 0 7/OS 2-41 50 / V <br /> Date: CCB# (if applicable) <br /> Applicant is the 0 Owner E Authorized Representative authorization to Apply form Attached <br />