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2:3 -0-0 g7 2 iq UTE <br /> Application for Onsite Date Stamp: <br /> n- Wastewater Treatment System Q <br /> ) ECMVED <br /> MARION COUNTY PUBLIC WORKS y� <br /> BUILDING INSPECTION DIVISION »j j 1 2 7 a fT <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 MARION COUNTY <br /> www.co.marion.or.us/PWBuildineInsvection BUILDING INSPECTION <br /> LA[ PropertyOwner Information <br /> ' ►lfl1�t V e100 4- T e0t4 TO1Z:rhO 2 2 33 Z R.l\$Cr,. [-.CQ )vim <br /> Name Mailing Address <br /> ,a -(--R .VL CR q 7 137 5-63-66/0-753 3 <br /> City,State,and Zip _m — r _ti (Area Code)Phone# <br /> . B.Legal Property Description _ <br /> ZZ F3 Z. t .ev Q Sa.t-k-+- ?c.) 1 012_ a71'37 <br /> Property Address City State Zip Code <br /> C4i2.f\\ 04 0(Zd0 <br /> Parcel# ✓ Tax Lot_``��1 Acreage or Lot Size AA^ <br /> Directions to Property: �t�"X �4c / SO AL Oq )Qla.�\ ' J J19�(4t 06 M et J p <br /> U 1 <br /> 1 C.ExistingFacility,//Proposed Faclhty/Water Information _ _ <br /> Existing Residential: `Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply:/ <br /> 2 L bg p / ['Public <br /> I��f� ��'� Name <br /> Number of Bedrooms Number o Bedrooms Number of Employees! Number of Employees/ Private w,(' 1 <br /> Seating Seating <br /> Well,Spring,Shared <br /> D.Type of Application __ _ <br /> ❑ Site Evaluation ❑ Renewal Permit — Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer DI The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> ❑ 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 /> nwe\ Ucyfut)0 Sb3 -6c1O— 833 <br /> - <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic. #(if applicable) <br /> P <br /> Zz 33Z �\0ev � c�;v* ?at,1 BIZ a\mccr �0re <br /> Applicant's Mailing Address O7i 37 Email: <br /> Signature Q Date: CCB# (if applicable) <br /> Applicant is the XOwner ❑Authorized Representative(form attached) <br /> G:\BUILDING INSPECTION\FORMS\SEPTIC\S-01 ONSITE APPL JULY 2023 REV 6.23.DOCX Rev 1/15,3/18,6/22,6/23 <br />