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2 3---ooe05SLt _pizin <br /> , „ , Application for Onsite Date Stamp: <br /> ;�;�-r Wastewater Treatment System D E© E J <br /> V E`- ' <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION AUG 012023 <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 MARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 BUILDING INSPECTION <br /> www.co.marion.or.us/PW/Buildinalnspection <br /> - <br /> A.Property Owner Information _ <br /> I1OI11 f~CtiriliIi PcevAz vf Po I , 8 <br /> Name { Mailing Address <br /> M L An^g e)1) &iZ Cfl3i,2 503--55-"LI2 <br /> City, State,and AV (Area Code)Phone# <br /> B.Legal Property Description <br /> IcD 1 1-ball Pr(LU-L ki 1\16 Sd De ci lao <br /> Property Address City State Zip Code <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> . <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> 100 ['Public <br /> cJIJ Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ <br /> Seating Seating ❑ Private <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 ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> Alteration Perm t ❑ Record Review ❑ Temporary Housing <br /> ❑ Major IN Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> DV- Klw-1 A- (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 /> Depart ent of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> Sejr i, <br /> Applicant's Name— ease Print Legibly Applicant's Phone Number DEQ Lic. #(if applicable) <br /> stic2. AM-- Ar .e4 , O/2 g1(3(2 <br /> Applic ailir}g�ddressfr qi Email: <br /> 1 /20�� <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the ❑ Owner ��j(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 />