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-'bbL/2 Le.CL\ <br /> Application for Onsite Date Stamp: <br /> Wastewater Treatment System i�� ; <br /> MARION COUNTY PUBLIC WORKS E_J <br /> BUILDING INSPECTION DIVISION AUG 07 2023 <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 MARK' s1 .4 + y <br /> (503)588-5147 Fax(503)588-7948 BUILDING INSPECTIOM <br /> www.co.marion.or.us/PW/BuildingInspection <br /> A.Property Owner Information'; <br /> G c 1/. Ill CC[.tty-[ //,'6 '. og/zoir/ 4fOe f C/- <br /> Name Mailing Address <br /> /I/5/ZM d/t ei73a7 5-q/ -Ken- re F,S' <br /> City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> G ?5 et-44 tr/3' '9, 5'47G0/1/ <br /> Property AddressQ — City State Zip Code <br /> I, 'J l9M -j <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> C.Existing Facility I Proposed,Facility/Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> ['Public <br /> f. Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ Private W* L L <br /> Seating Seating <br /> Well,Spring,Shared <br /> D.,,Type of.Application . <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for:.1: Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> 0 Major 0 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 /> arygif t6IAArat -iir3— <br /> - <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic. #(if applicable) <br /> l/ AlFRtzo-.v R o a Gr fez cm aA 173f4 a-yr tc3.96/q G 07/9i ,cozy <br /> Applicant's Mailing Address Email: <br /> ' • mod 6/ '1/�3 <br /> Signa`fu re� Date: CCB# (if applicable) <br /> Applicant is the riTA 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 />