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OL')' tb 355°1 <br /> .,,,, „ , Application for Onsite Date Stamp: <br /> Wastewater Treatment System <br /> ECEIVED <br /> MIMARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION APR 0 2 2024 <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 . <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PWBuildiniInspection <br /> • A..Property Owner.Information <br /> ., 0\e\f\0\ �Y owe <br /> ame Mailing Address <br /> City,State,and Zip _ (Area Code)Phone# <br /> B.Legal Property Description <br /> 1 l L `tl CA- a c),,WM _ al 131,i <br /> Property Address City State Zip Code <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: - <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: %V er Supply: <br /> ilt <br /> blic <br /> Name <br /> Number o Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ <br /> Seating Seating ❑ Private <br /> Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> kVRepair Permit ❑ Permit Transfer ElThe Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ 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 /> \-\(\e\ --1(okQck\)\/\cr SY) 7(15 ZSLt3 ( ,)ffir <br /> A licant s Name—Please Print Legib Applicant's Phone Number DEQ Lic.#(if applicable) <br /> b&i( SbLI 1 y s ' Q l .e(exc fen <br /> Ap li a iling Address mail: <br /> ( 31' - GI— z— z --t C-Iq sl <br /> Sig ture Date: CCB# (if applicable) <br /> C:\USERS\ANAJERASANCHEZ\APPDATA\LOCAL\MICROSOFT\WINDOWS\INETCACHE\CONTENT.OUTLOOK\3T7CT1Q3\S-01 ONSITE APPL JULY <br /> 2023 REV 6.23.DOCX Rev 1/15,3/18,6/22,6/23 <br />