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r 1111, <br /> 5135---22-01,02-08- PP in-r- <br /> Application for Onstte For t it, t`,tr Only: Dore Swop. <br /> Wastewater Treatment System <br /> - <br /> 11111111 <br /> COUNTY PUBLIC WORKS Date Received <br /> MARION D EcE w -F Received by .22) <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silvertort Rd NE JAN 10 2022 <br /> Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fos(503)588-7948 Receipt a MARION COUNTY <br /> Activity# BUILDING INSPECTION <br /> W11, X0,11-taFttntOr-usTIViDuildilliansiteeti911 <br /> A.Property Owner Information <br /> i On_141.,_Re.0_22._c616_kititiLfri, i X Or 47 123,,59 _603 T30 -6 0203 <br /> Name <br /> .. <br /> N Mailing Address City, S te,and Zip (Area Code)Phone tat <br /> II Legal Property Description <br /> 4..., +.. 09., E le D-icoceo , a 7e,; 4c 0.-.2 3 -k <br /> Ls g41 Dets....4.44ion Tais-bed 012.&ie D4o,, 74,:s) AdreIgrartot44 <br /> Bitelt-' I <br /> Property Address City 1.- i. State Zip Code <br /> Directions to Property: ot‘.. E.. s,--k god,I rev 0( reattic ilicli., <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Ens' ting Facility: Proposed Facility: NWater Supply: <br /> .15(Sinzle Family Residence P7,.! Single Family Residence 0"tiblic ,f <br /> \ 2NName <br /> Number of Bedrooms Number of Bedrooms El Private <br /> 0 Other 0 Other Well, Spring,Shared <br /> D.Type of Application <br /> 9_,Site Evaluation 0 Renewal Permit )SIAuthorization Notice for: <br /> Co truction Permit 0 Permit Reinstatement „F Replacing a Dwelling <br /> / 21 Re Permit 0 Permit Transfer The Addition of One or More Bedrooms <br /> J4aj0r 0 Minor 0 Existing System Evaluation 0 Personal Hardship <br /> ,,,... <br /> ation Permit 0 Record Review 0 Temporary Housing <br /> 0 Major 0 Minor 0 Other El Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> D 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 /> Nea& fil . la.Pt I 5-0,3 .7'30 - 203 <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> ... P"....r, <br /> -22 6 i cr1318 — <br /> Apish 's Mailing Address / <br /> ignature Date: CCB# (if applicable) <br /> Applicant is the wner El Authorized Representative 0 Authorization to Apply form Attached <br /> G\BUILDING INSPECTIONTORMS\SEPTIOS-010NSITE APPl.SEPT 2018.DOCX Rev 1/15,3/18 <br />