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a3. C561 9 <br /> Application for Onsite Date tZtirkg Wastewater Treatment System <br /> MARION COUNTY PUBLIC WORKS RECEAVED <br /> BUILDINGs slve n Rd DIVISION AUG 212023 <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 MART l7 N CU U N ( <br /> www.co.marion.or.us/PW/Bui1dinaInsnection BU%LDIN�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 /> 57 pie bk p(.vr, Ldoi itE. Salem OR 97317 <br /> Property Address City State Zip Code <br /> 2 .0 3 <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 /> 3 QPublic <br /> Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ ® rivate 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 ❑ Permit Reinstatement 0 Replacing a Dwelling <br /> ❑ R air Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> Major ❑ Minor yg Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit uu Record Review ❑ Temporary Housing <br /> El Major ❑ Minor ❑ Other ❑ 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 /> re Date: CCB# (if applicable) <br /> Applicant is the Owner 0 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 />