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(33-60^1tR\ <br /> Application for Onsite Date Stamp: <br /> Wastewater Treatment System <br /> 1.111 MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION r AUG 2 1 2023 <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/PWBuildinelnspection <br /> A.Property Owner Information <br /> Donovan Sippel 5756 Fruitland Rd NE <br /> Name Mailing Address <br /> Salem, OR 97317 (503)551-6483 <br /> City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> .'?-60 Noble Pi,t,,,,. AiE Salem OR 97317 <br /> Property Address " City State Zip Code <br /> v� <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: Gravel road access located at 5756 Fruitland Rd NE Salem, OR 97317 <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 Emp oyees/ Number of Employees/ private Well <br /> Seating Seating <br /> Well,Spring,Shared <br /> D.Type of Application <br /> Site Evaluation 0 Renewal Permit ['Authorization Notice for: <br /> Construction Permit El Permit Reinstatement El Replacing a Dwelling <br /> ❑ R it Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> [Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> 0 Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major El Minor ❑ Other El Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 0 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 /> Donovan Sippel (503)551-6483 <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic. #(if applicable) <br /> 5756 Fruitland Rd NE Salem, OR 97317 donovansippel@gmail.com <br /> Applicant's Mailing Address Email: <br /> 4alure Date: CCB# (if applicable) <br /> Applicant is the IIVSOwner ❑Authorized Representative(form attached) <br /> G:\BUILDING INSPEC ION\FORMS\SEPTIC\S-01 ONSITE APPL JULY 2023 REV 6.23.DOCX Rev 1/15,3/18,6/22,6/23 <br />