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Application for Onsite 013_ 0 b <br /> Date Stamp. <br /> Wastewater Treatment System <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDIS 55 S I ECTItonOd NEON DIVISION IECEn9i <br /> DEC 26 2023 <br /> Salem OR 97305 MARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 BUILDING INSPECTION <br /> www.co.marion.or.us/PW/BuildinEInsnection <br /> A.Property Owner Information <br /> Name Mailing Address <br /> S G.\e C- ',-7 3 l 7 5.03 S S l 4120 <br /> City, State, and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> G2, D <br /> �8 3(0 �� r� P � SE �.� v <br /> Property Address City State Zip Code <br /> 12:0211# (Acraagc-ar atST <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> 9 ['Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ Z(Priva - <br /> Seating Seating <br /> pring, Shared <br /> D.Type of Application <br /> 14 Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> El Repair Permit ❑ Permit Transfer El The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor lP 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 /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic. #(if applicable) <br /> Ir-�3kd q ,rci�,�yp Q C11MC�:l..co <br /> Applicant's Mailing Address Email: ( Q <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 />