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Application for Onsite Date Stamp: <br /> Wastewater Treatment System EC .EFVED <br /> 11111111 MARION COUNTY PUBLIC WORKS � OCT 16 2�23 <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 MARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 BUILDING INSPECTION <br /> www.co.marion.or.us/PWBuildin2Inspection <br /> A.Property Owner Information <br /> Tess TDran 0/r, a Toran PO grr c( 7-, 3.8'O Tu540. Ave_ <br /> Name Mailing Address <br /> &er Iteri 5 Off' er?O2L' ��� - 5-0 7- 5q`7// <br /> City, State, and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> i 2 q L1- <br /> `C�' c7:-/h/ehem N <br /> 9r _ C7er via l'5 0P ,17D2C' <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 /> 3_ Name <br /> Number Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ vale <br /> Seating Seating <br /> Well,,pring, Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement 1 ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation I i 'ersonal 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 /> Q latex Toram Co 3-CO7 -5-ziy/ <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> cxA6 Po go;, Li3 3g0 POu9!a9 ,4- /IJe- ranp4'//, Q3s40// cvr ,( <br /> Appli.:t..3 ing Address 6 erVa is op q Y(2,6 Email: <br /> ilk joist fir ( O - 1 - 1 ) <br /> Si. •it ate: CCB# (if applicable)f <br /> Applic.0 . the X Owner Authorized Representative(form attached) Or/jn rad/` APO, ' <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 1V/ <br />