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Application for Onsite nateSta _ej _ <br /> ;�_.. Wastewater Treatment System _ Ur <br /> MARION COUNTY PUBLIC WORKS <br /> OCT 2 0 207' <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE MARION COUNTY <br /> Salem OR 97305 BUILDING INSPECTION <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PWBuildingInspection <br /> A.Property Owner Information <br /> Do()Qcc p/LoPexr.c(' Z. S > STA-7— c SC <br /> Name Mailing Address <br /> Ol 6172i7 So3 - 370 -- 2 S/o <br /> City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> 2- Z-I f0L es% N 4 Veh L✓i ' S <br /> SA}L ✓_ mot'2.2 c 2 <br /> Property Address City State Zip Code <br /> PA—a—,- 3 ,2. 2?37 P.ISY /hL0,2 O83WOSQo6iyoo q .5? Aces <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: 1 h+'-AN0 p,2 tS NEA/LESr- C t 01-C .GREET <br /> Fv;vRt A 02=SS tar= PoACST- HAv€M ✓hr <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Residential: Proposed Residential:JX. Existing Commercial: Proposed Commercial: Water Supply: <br /> 6-1 ['Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ <br /> Seating Seating ] Private f-1/ <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 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 /> ha.(-'4Ma1 LA-'CAI )4 g o3- 93 Z- 2 o 7c) <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic. #(if applicable) <br /> S )y ) S + St SE - cam,,,, 6 X. 97J( k��� k��� a�► . A e+ <br /> Applicant's Mailing Address Email: <br /> l0l4/2„.3 SSyzl <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the .Owner ❑Authorized Representative(form attached) <br /> C:\USERS\KENT\DOWNLOADS\(MS WORD).DOCX Rev 1/15,3/18,6/22,6/23 <br />