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Application for Onsite Date : <br /> los <br /> Wastewater Treatment System <br /> MARION COUNTY PUBLIC WORKS D ' <br /> EC <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE AUG 212023 <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 MARION COUNTY <br /> www.co.marion.or.us/PW/Buidineinsnection BUILDING INSPECTION <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 /> 80 Al s is le ?h4 LJay NE Salem OR 97317 <br /> Property Address City State Zip Code <br /> 2.00 <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 /> Y ❑Public <br /> Name <br /> Number of Employees/ Number of Employees/ Well <br /> Number of Bedrooms Number of Bedrooms Seating Seatingprivate <br /> Well,Spring,Shared <br /> D.Type of Application <br /> ®, Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit El Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ R it Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> al Major ❑ Minor El Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major El 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 /> 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 Ad ss, Email: <br /> 81ro42023 <br /> e Date: CCB# (if applicable) <br /> Applicant is the Owner ❑Authorized Representative(form attached) <br /> G:\BUILDING INSPECTION\FORMSISEPTICIS-01 ONSITE APPL JULY 2023 REV 6.23.DOCX Rev 1/15,3/18,6/22,623 <br />