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,, Application for Onsite <br /> -7�j Date Stamp: <br /> ,diu 2-3-00 [per- -( <br /> --- _•) Wastewater Treatment System <br /> E ECI11M! TT <br /> MARION COUNTY PUBLIC WORKS D <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE SEP 18 2023 <br /> Salem OR 97305 MARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 BUILDING INSPECTION <br /> www.co.marion.or.us/PW/BuildinEInspection <br /> A.Property Owner Information <br /> 3 BUJ <br /> `'arn e.,\a 1�0x� �C Sao w S . <br /> Name Mailing Address <br /> 1- ,N). ( 1\2, ,Lam. g1 5 50 0-1. -3R(Q 9 <br /> City, State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> O eS Sho es � U a 1�e, 0� G- aS <br /> Property Address City State Zip Code <br /> Parcel# . Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information _ <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> ❑Public <br /> a Name <br /> Number o Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ private <br /> Seating Seating <br /> Cab 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 Permit ❑ Record Review -! emporary Housing <br /> ❑ Major ❑ Minor ❑ Other lib onnecting 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 /> v- c __0,Ar m-z<-- )3 &G 'zSco 9 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> s)(68 ‘Clc).w Wy k::., ?AT 1 M F_ a. rou,t cz <br /> pplica is Mailing Ad r s Email: <br /> q a <br /> ature Date: CCB# (if applicable) <br /> Applicant is the V 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 />