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023- b1 oa as <br /> Application for Onsite Date Stamp: <br /> iiii <br /> --_„_ Wastewater Treatment System <br /> MARION COUNTY PUBLIC WORKS D <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE - DEC 1 c 2023 <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 MARION COUNTY <br /> www.co.marion.or.us/PWBuildingInspection BUILDING INSPECTION <br /> A.Property Owner Information <br /> ILL she.( 9C63 JactScl,-kttt d SE <br /> Name Mailing ddress <br /> Jc km OR 11& (5-6k Oa-090 7 I <br /> City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> 9 ,c3 jot.cvsn R.11 ( a 5 ` a1ewk. OZ. 9130C <br /> Property Address City State Zip Code <br /> Gain a�a.c. <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: Ttecoc. Ce-tk CLAB4)3cm-040 t L.44pGA. arrn y&\ f' Sake acce SS <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 Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ 0-Private Private V(.12t1 <br /> Seating Seating w <br /> Well,Spring,Shared <br /> D.Type of Application <br /> 74; Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> El Repair Permit El Permit Transfer ❑ The Addition of One or More Bedrooms <br /> El Major ❑ Minor El Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit El Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 4b Yrtbe- y ❑ 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 /> Jkeve MoSek` (4800 I <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic. #(if applicable) <br /> l ,J C'-s..7G11 Cli _0C, 3ftYtAQ.Ae,( n61 AJe.Ci301 <br /> Applicant's Mailing Address Email: <br /> 1.11 k k I aoa3 - <br /> Signature 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 />