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2,5-OO' 50 C-JaL <br /> Application for Onsite Date Stamp: <br /> Wastewater Treatment System <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DMSION OCT 20 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/PW/Buildin2Inspection <br /> A.Property Owner Information <br /> 9OQ4t c PROPL,t , s LL L ! 7%7 Si, s S( a <br /> Name Mailing Address <br /> SA�Frti 0.2, 9).3/7 So3 - 2>o -25/6 <br /> City, State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> ZFSS/ Fc. CEr" 1-/Avck uiAy <br /> e'r.-s G 2 `1 2�a Z <br /> Property Address City State Zip Code <br /> Pfru .142 Rom- Y72 Y PAc� l`to AR 081woTa ool00 19RoPoc&6 3. 417 Ac,-c-s <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: 1 NE--A NO 04 C,Lo,cs s r/2dc'T <br /> Fu;u2E A4Rcs1 ? o (Qc Fote r /14veN 44Y <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Residential: Proposed ResidentialX Existing Commercial: Proposed Commercial: Water Supply: <br /> / ❑Public <br /> ( 1 Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ Private IA/(._._ <br /> Seating Seatingxi <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 /> El 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 /> 1(e-A r �Qti�M".. ` ku,,,E.•,., itAZo 3 - C3 L- 26 Sa <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> s) q7 Sr- SC ...("A � 04_ 9»17 keA t� KK��a� . Act- <br /> Applicant's Mailing Address Email: <br /> /6 /y /23 ES Y 2-1 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the Owner ❑Authorized Representative(form attached) <br /> C:\USERS\KENT\DOWNLOADS\(MS WORD).DOCX Rev 1/15,3/18,6/22,6/23 <br />