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Application for Onsite -66ga�` � U - <br /> Ds t <br /> Wastewater Treatment System.7 E C E M t <br /> 1111 MARION COUNTY PUBLIC WORKS Nov 0 6 2073 <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 MANION COUNTY <br /> (503)588-5147 Fax(503)588-7948 BUILDING INSPECTION <br /> www.co.marion.or.us/PW/BuildingInspection <br /> A.Property Owner I formation <br /> L ilo& 6 ervIP 2o7S7 <br /> /%15ne Ma' ing Address <br /> &,(ex-A O g, 9 o Z 5- <br /> o3 67t <br /> iState,and Zip (Area Code <br /> City, )Phone# <br /> B.Legal Property Description / <br /> 67 5 l7 Ca se, X ALL-(6[0\ o, 9 700Z <br /> Property Address City State Zip Code <br /> Di)-V\ ( °AO I161) <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 /> 3 ❑Public <br /> Name <br /> Number of Employees/ Number of Employees/ <br /> Number of Bedrooms Number of Bedrooms Seating Seating Private <br /> Wel 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 /> ❑ 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 /> 141<e r c��' 14/cF.7 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic. #(if applicable) <br /> Applicant's Mailing Address Email: <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the ❑ Owner ❑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 />