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023-ctic\J,1 <br /> Application for Onsite n <br /> (� Vt't' For City Use Only: �t�p'`1// <br /> 44 <br /> IF, n <br /> - Wastewater Treatment System city of <br /> III <br /> Date Received _ 4AY o 9 2023 <br /> MARION COUNTY PUBLIC WORKS Received by • <br /> BUILDING INSPECTION DIVISION Zoning by iv <br /> E 1�.Ea ��s` ly <br /> 5155 Silverton Rd NE Feei�" � � � �� <br /> Salem OR 97305 <br /> (503)588-5147 Fax(5.03)588-7948 Receipt# <br /> www.co.marion.or.us/PW/Buildinglnspection Activity# <br /> --- - / <br /> =----- P � B..�__._ _-__mA PropertKOwner Information :� --_ . _-- - I <br /> Q <br /> rlltwl1 G IG(L(JC./1 C� Z 2- en fT �G, I'A+1ci t J-3)) i?1 Z!e- 6l e.9 <br /> Name _ Mailing Address City, State,and Zip S (Area Code)Phone# <br /> _._._._ - ._.i. ' .'- �___.' lkLegal Property Description 4_ <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> Property Address City State Zip Code <br /> Directions to Property: Ci ZZ1 --vore„,-, - f¢=y re/itet% . <br /> ^ __. _C Existing Facility)Proposed Facility/Water Information. -^_. _._' i <br /> Existing Facility: 1 Proposed Facility: Water Supply: <br /> [,Single Family Residence Single Family Residence ❑Public <br /> 2 tom Name <br /> Number of Bedrooms Number of Bedrooms g. Private VeG of <br /> ❑ Other - __ Other _ _ _Well,Spring,Shared_ <br /> L. __ . �..IA.. t - _ D.Type of_A_pplicatioli = __ __� ___ -- - —_i <br /> ❑ Site Evaluation 0 Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit 0 Permit Reinstatement ❑ Replacing a Dwelling <br /> ® Repair Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> I'Major 0 Minor 0 Existing System Evaluation ❑ Personal Hardship <br /> El Alteration-Permit 0 Record Review ❑ Temporary Housing <br /> 0 Major 0 Minor ❑ Other 0 Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> At A,,,\ '1 ), atv 0 Other-Please Specify <br /> If the required fee and atta ments 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 /> Depaituient of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> Bethel Excavating 503-743-2343 36198 • <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> PO Box 504 Turner, OR 97392 <br /> A'Tlicant's Maili g Address <br /> ..N......vakitA CO- - a.5 44551 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the❑ Owner ©Authorized Representative ❑Authorization to Apply form Attached <br />