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91 -C)C5-16)G\ <br /> Application for Onsite Date Stamp: <br /> Wastewater Treatment System 15) <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION — AUG 212023 - <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 MARION C.:JUNy! Y <br /> (503)588-5147 Fax(503)588-7948 BUILDING INSPECTION. <br /> w ww.co.mario n.or.us/PWBuildinenspection <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 /> 'gyp Nolie- FL iced /yam' Salem OR 97317 <br /> Property Address City State Zip Code <br /> 2 .06 <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 /> DPublic <br /> Name <br /> Number of Employees/ Number of Employees/ Well <br /> Number of Bedrooms Number of Bedrooms Seating Seating Private <br /> Well,Spring,Shared <br /> D.Type of Application <br /> Xt Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement 0 Replacing a Dwelling <br /> ❑ R it Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> Major ❑ Minor 0 Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit 0 Record Review 0 Temporary Housing <br /> ❑ Major 0 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 /> Situ/Z,2 3 <br /> ignature Date: CCB# (if applicable) <br /> Applicant is the ,Owner 0 Authorized Representative(form attached) <br /> G:\BUILDING INSPECT'ION\FORMS\SEPTIC\S-01 ONSITE APPL JULY 2023 REV 6.23.DOCX Rev 1/15,3/18,6/22,6/23 <br />