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2'/o o crg7 Eve <br /> ,qv 1 Application for Onsite Date Stamp: <br /> --- Wastewater Treatment System <br /> I�17; I1r- �� , _ Ir- r-, <br /> MARION COUNTY PUBLIC WORKS j I '; <br /> BUILDING INSPECTION DIVISION !t ''' (.�d" `' ,) 'A`7I e'; <br /> 5155 Silverton Rd NEII "" <br /> Salem OR 97305 M A R i o C :_,• _.:',i Y <br /> (503)588-5147 Fax(503)588-7948 r3 L I LD:N C ;N S P E C T! i` <br /> www.co.marion.onus/PW/BuildingInspection <br /> NA.Pro a 1y Owner Information <br /> -:./.÷:4 V 4-12:7,€"4- <br /> /9 F9‘.al-e--3-,L-ee ,X ct e <br /> Name Mailing Address <br /> City, State, and Zip (Area Code)Phone# <br /> B Legal FroPertY;Descnption _ -__ ',-_ .- - ; , _____ ___., am _ _.-___ •: _._ f <br /> 6q7 67-41- 7_,e9-z ,a717V-V12; Cie 97-.z,5- <br /> Property Address City State Zip Code <br /> ®7/row‘,®or/06 s�egaG 7 ,Q �- <br /> t , Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> C:Ears kifiaty{/,Proposed FacilrtY C Water Information j <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> 3 :Public <br /> N4511..., <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ Private ' ` - Q <br /> Seating SeatingLN Well, <br /> . Spring, Shared <br /> ;;l) T e of A lication <br /> -- <br /> igio Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit El Permit Reinstatement El Replacing a Dwelling <br /> El Repair Permit 0 Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major " ❑ Minor ❑ Existing System Evaluation El Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> El Major El Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> ❑ Other—Please Specify <br /> 1 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 /> ScA/vr`d ) youl400,Corn <br /> Applicant's Mailing Address Email: <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 />