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Application for Onsite Date Stamp: <br /> ;_,. Wastewater Treatment System 2 3.0 -p MA j <br /> MARION COUNTY PUBLIC WORKS D lL C I [I V c' <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE UOCT 0 4 <br /> Salem OR 97305 20 <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PWBuildinzInsnection MARION COUNTY <br /> BUILDING INSPECTION <br /> A.Property Owner Information <br /> Ross 17605 Pa;h r Ate R.e:1 <br /> Name Mailing Address <br /> hiKaivd oR 1703.2 503 - 5'/5 -5o GI.� <br /> City, State, and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> 17405 painder Leo Rd tk 6lard O1a. 47703,2 <br /> Property Address City State Zip Code <br /> a3. / <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 /> 4 2 ['Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ $ Private We I I <br /> Seating Seating <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 /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> Applicant' ailing Addre c Email: <br /> 04423 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the X 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 />