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Z3 - 010ti( 3 'r14r <br /> Application for Onsite Date Stamp: <br /> -7�;w Wastewater Treatment System <br /> Y <br /> -_MO MARION COUNTY PUBLIC WORKS �-) ��- (� n I'. �� 1- -- <br /> BUILDING INSPECTION DIVISION I^ 1 f <br /> 5155 Silverton Rd NE • <br /> Salem OR 97305 - d C 7C 2 9 2023 --J <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PWBuildinsInsoection <br /> MARION COUNTY <br /> ' 1,41,,D1Nt INISPECIPN <br /> A.Property Owner Information <br /> 5ecu i ce- /Vc1 14-o, Li q 77 Rett r k Le/S <br /> Name Mailing Address <br /> CAI oR `173ot S03 -S06 -r1S10 <br /> City,State, and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> LIg2q RR i. Rack Lars ..C6 icon . OR Cj73oZ <br /> Property Address City State Zip Code <br /> 2 <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: 6 . ; t, -1 , ,f? ,, e., C k f 14 e P <br /> '..TO0,04 (nn4:( 7AV I1"A -Icy'e1 4 Po, t' il.rtQ,,( r ‘.e'lt be.. I." 4.11/ le <br /> Pct-.-1 -he },;It <br /> C:Existing Facility/Proposed Facility/Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> OPublic <br /> Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ a private irvG// <br /> Seating Seating <br /> Well,Spring,Shared <br /> D.Type of Application , <br /> El 6Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> Repair Permit Cl Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ PersonalHardship <br /> ❑ Alteration Permit El Record Review ❑ Temporary housing <br /> Cl 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 /> Applicant's Name-Please-Print Legibly Applicant's Phone Number DEQ�Liicc.#(if applicable) <br /> we 96 c i _roil 7itr F-Q q?734�.... 6 ?4 ct. 6/(?t 1G( r , (G <br /> Applicant's Mailing Address Email: <br /> -� O&M t11 12./27//i3 lit/ SS) <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the El 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 />