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a3 �bl D�C1 <br /> Application for Onsite Date Stamp. <br /> - Wastewater Treatment System <br /> MIMARION COUNTY PUBLIC WORKS BUILDING INSPECTION DIVISION D Ec i(� <br /> U\ <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 DEC 28 2023 <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/Buildinalnspection MARION COUNTY <br /> A.PropertyOwner Information BUILDING INSPECTION , <br /> 1�. N 15 fveNsofq PO Sax 12394 <br /> Name Mailing Address <br /> SU-ern O . 573c-9 513- 532- 5V 5L1 <br /> City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> (D1o91 SY144lit4E CP. S . SALj oe 9730i. <br /> Property Address City State Zip Code <br /> o t 3 w►i c as 300 11.91 -S <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: Skyk.ltlE 2fl — PAST u\TAE. SnikibS Z;(— n , ..E5 v2 QvgNT <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> o-bedroo+n5 <br /> . 14+' ( BA n4 wore) Pik N/,( ['Public <br /> /t Name <br /> Number o Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ CT <br /> Seating Seating Private �✓LLL <br /> Well,Spring,Shared <br /> D.Type of Application <br /> Site Evaluation D Renewal Permit DAuthorization Notice for: <br /> Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major 0 Minor ❑ Existing System Evaluation 0 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) M c%lNeC <br /> X Other—Please Specify BAQ..$(UGC: BA-NeCom <br /> adclti.'vn <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 /> -i 0 ..sl tE t4 5(92-13Z-5E5 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic. #(if applicable) <br /> c .o . to)% tidy sk erA, oe. il3b1 do i,€61 V 5rna5an((,(1.. ^ <br /> Applica is Mailing Address Email: <br /> l t7j21'Z7 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 71,Qwner ❑Authorized Representative(form attached) <br /> G:\BUILDING INSPECTION\FORMS\SEPTIC\S-0I ONSITE APPL JULY 2023 REV 6.23.DOCX Rev 1/15,3/18,6/22,6/23 <br />