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a3-Ob5s q <br /> Application for Onsite Date Stamp: <br /> Wastewater Treatment System ® I C E 0 N I <br /> 13 <br /> MARION COUNTY PUBLIC WORKS JUL 10 2023 <br /> BUILDING INSPECTION DIVISION _ <br /> 5155 Silverton Rd NE MARION COUNTY <br /> Salem oR973o5 BUILDING INSPECTION <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/BuildinzInspection <br /> A.Property Owner Information <br /> 84uL_ �� e% I E7/ )n6E/er Ate NE <br /> Name Mailing Address <br /> 14.b4 (7,e g793 Z 97 — 't09 - 02g7 <br /> City, State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> I 2L'/'a F;L3ER r AYE N kite 664RP q7032— <br /> Property Address City State Zip Code <br /> /200 /s Os- A-6/Zt5 <br /> Parcel# // Tax Lot n Acreage or Lot Size <br /> Directions to Property: ( ,ji5/T A eY f (/ /z d 7o /e2 LL/ <br /> C:Existing Facility/Proposed Facility/Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> ❑Public <br /> Name <br /> Number of Bedrooms 'Number o edrooms Number of Employees/ Number of Employees/ It pr. e <br /> Seating Seating <br /> . Well, pring,Shared <br /> D.Type of Application <br /> Site Evaluation ❑ Renewal Permit <br /> ❑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 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 /> signature, cart' t tthe' correct,and he <br /> reby my I certify that information I have furnished is h reby 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 /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic. #(if applicable) <br /> Applicant's Mailing Address Email: <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the ❑ Owner ❑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 />