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Application for Onsite Date Stamp: <br /> ;_.. Wastewater Treatment System <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PWBuildinzInspection <br /> A.Property Owner Information <br /> n?1 6423..pP (DCI2.(o -50nn7Vi eu r.Q <br /> Name Mailing Address <br /> Sclera of- Si OS 539 - <<i-oSt5 <br /> City, State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> (`1 ec..: ,nA A/F Scl ef-. —t 70 S.— <br /> Property Address City S ate 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 /> 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 /> El Site Evaluation El Renewal Permit Authorization Notice for: <br /> El Construction Permit El Permit Reinstatement El Replacing a Dwelling <br /> El Repair Permit El Permit Transfer El The Addition of One or Moreoms <br /> El Major ❑ Minor ❑ Existing System Evaluation litt"ersonal Hardship <br /> El Alteration Permit ❑ Record Review Temporary Housing <br /> El Major El Minor El Other El Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> El 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 /> Ac,i4knpt,.r 13. h-d-c.pp S 7 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> G SaniticststLi 0. A(i1� Ssler. QfL 5-770.s �G,s�r-rev_�•e14/0 "NS:l_c-,AA <br /> Applicant's Mailing Address Email: <br /> Art_ /0/a/262y <br /> Signature Date: l CCB# (if applicable) <br /> Applicant is the []'Owner El 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 />