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2 <br /> ,,, ,, Application for Onsite Date Stamp: <br /> Wastewater Treatment System iiAlv <br /> NE,_........\ <br /> '�. MARION COUNTY PUBLIC WORKS D1C -Fi <br /> BUILDING INSPECTION DIVISION <br /> D <br /> 5155 Silverton Rd NE JUN 10 2024 <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 MARION COUNTY <br /> www.co.marion.or.us/PWBuildinslnspection BUILDING INSPECTION <br /> A Property©wner'Information <br /> Name Mailing Address <br /> SA IC 1A, 0 IZ K 7 317 5-(33- .5 6 7— 7 5(5 1 <br /> City,State,and'Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> 1 Lic1$ CAA cA46 ITV...y jig S A/cir, d7Z 'i 73 /7 <br /> Property Address / City State Zip Code <br /> Parcel# Tax Lot Acreage or Lot Size _ • <br /> Directions to Property: <br /> C E'xistingFacthty I Proposed Facility IWater <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> ['Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ Private <br /> Seating Seating <br /> Wel, Spring, Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit KAuthorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ® The Addition of One or More Bedrooms <br /> ❑ Major El Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major. ❑ Minor El 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 /> (7ck(, 54&-i-1 e/-- Sa 3- _5-07 —7effai <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> S z e e.°�Cr sh C 4/6- LY 3 f'hG.,-(, 4j 141 <br /> Applicant's Mailing Address Email: <br /> er &Sture Date: CCB# (if applicable) <br /> Applicant is the Nc4 Owner El 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 />