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���'` Application for Onsite 090 <br /> c 2 _064,y _r Air-it <br /> .„, ,„� pp For City Use Only: _ TV"E 0 <br /> w: <br /> Wastewater Treatment System City of <br /> =ter„ <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by APR p 4 2022 <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee MABIOV COUNTY <br /> Salem OR 97305 Receipt# BUILDING INSPECTION <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PWBuildint=_Insnection Activity# <br /> A Pro_perty Owner Information r . _ Y3 ;,; <br /> Larry loomis-Price %?S& #.l(en�(Je Dc 36 Sajeh, ,OR g7,Oz 823-971-7800 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> T 8 R-4E SEC-32BD--T-L•1600— --'•Le � ` u-'--- __ :49-acre-_ _,__ __,I. .k <br /> Legal Description Tax Lot Acreage or Lot Size <br /> RANDALLS ELKHORN SUBDIVISION BLOCK 2 LOT 5 & VAC RAN <br /> Subdivision Name Lot Block <br /> 35404 FRANCIS STREET, SE LYONS OR 97358 <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> : _ . ,; . -'.-C Existing Facility/Propo'sed Facility/Water Information • 7 <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Single Family Residence x❑ Single F3amily Residence ['Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms ] Private Well <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> D T e of A lication <br /> . . <br /> El Site Evaluation ❑ Renewal Permit Authorization Notice for: <br /> El Construction Permit El Permit Reinstatement Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> El Major El Minor ❑ Existing System Evaluation El Personal Hardship <br /> El Alteration Permit El Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other El Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> El Other—Please Specify <br /> If the required fee and attachments are not included with this application, it will he 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 /> Larry loomis-Price 823-971-7800 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 4S-FI-R-ETtleRN-P-L. .94E—weeetikts0S7Dt77382 igsg ijik,f,,,(e .1)— ,.S <br /> Applicant's , ailin s £le N.l ) D A C1 73 D 2, <br /> /_ ' yy/2„..Signat.re Dat CCB# (if applicable) <br /> Applicant is the t1 Owner El Authorized Representative ❑Authorization to Apply form Attached <br /> l <br />