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°.1'k Application for Onsite For City Use Only: <br /> - Wastewater Treatment System City of R <br /> EC EeH Ei <br /> D <br /> Ili <br /> Date Received <br /> 1V[t►RION COUNTY PUBLIC WORKS Received by 14u v 0 2 2022 <br /> BUILDING INSPECTION DIVISION Zoning by <br /> TY <br /> 5155 Silverton Rd NE I ���� <br /> Salem OR 97305 Fee BUILDING INSPECTION <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> nal:— :at;_ £,r•;Z�:?> :�.,1lc. -.u.,.,,. Activity# <br /> • <br /> A.Property Owner Information <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 /> /7 £ »w sue, 4, -v,/h. 9735 <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility 1 Water Information • <br /> Existing Facility: Proposed Facility: Water Supply: <br /> RSingle Family Residence 0 Single Family Residence ❑Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms XI Private 4./ , <br /> ❑ Other ❑ Other <br /> Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation 0 RenewaI Permit ❑Authorization Notice for: <br /> If Construction Permit 0 Permit Reinstatement ❑ Replacing a Dwelling <br /> Repair Permit ❑ Permit Transfer 0 The Addition of One or More Bedrooms <br /> 0 Major 0 Minor ❑ Existing System Evaluation <br /> ❑ Alteration Permit ❑ Personal_Hardship Record Review 0 Temporary Housing <br /> ❑ Major ❑ Minor ❑ 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 /> Lone Pine Corner Septics Inc. 503-873-7157 37003 R-I-100 fZ_ _��_3 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lie_# (if applicable) <br /> 8778 Cascade Hwy NE Silverton, OR 97381 <br /> A plicant's Mailing Address <br /> , —E // l aO 177063 <br /> Signature Date: CCB# (if applicable) <br /> • <br /> Applicant is the 0 Owner A Authorized Representative 0 Authorization to Apply form Attached <br /> 1 <br />