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c9L1-t94-1 5)9 <br /> Application Onsit. forVat*4h1m9F <br /> Wastewater Treatment System <br /> RECEIVED <br /> MARION cOUNTY PUBLIC'WORKS <br /> BIjMNG INSPECIION DIVISION <br /> 5155 Siiverton RdNE JUN 1 3 2024 <br /> Salem OR.97305 <br /> (503)588-5147. Fax(503).5884948 <br /> wwwcomarfionionus/PW/BuildingInsuection. <br /> 0,C4104_, 6.9k:m.t.,12, 1155141 Lit SE <br /> 'Name <br /> Arbut45ON ote 563ff107.t4.1.471z <br /> City,State,and Zip (Area Code)Phone <br /> • <br /> 115.51D• lat.Ltel(wet Lv tilmr.Mt.14.4 q132.5. <br /> Property Address City State Zit,..Code <br /> .-041.W1:3DA 011:60 ke. <br /> Pared# Taxtot Acreage-or:Lot Size <br /> POCciiOasloi.I".k.op0* <br /> . , <br /> 7:20 • .‘. - <br /> kidstiiigsResidentialt Proposed Residential: Existing Commercial: Proposed Conuttereial: Water Supply; <br /> ERubuic <br /> 3 Name, <br /> NurqbLT, :efEhiptosTest N91*.gfgrppjoyetsi_ ro private we...It <br /> etBedroof6: Ntutber ofBedtociiiig' -$00100,• Se.st4g. <br /> Well,Spring,Shared <br /> o Site Eyaluation; O.Renewal Perniit KAttthorilationk NotiCelor:' <br /> O ConstructionTermit 0: Permit.Reinstatement Replacing.aflwelling <br /> 0 Repair Pemut 0 fidnnit Transfer U The Addition:of One,or More Bedrooms <br /> El Major 0 Minor El Existing System Evaluation El Personal Hardhip <br /> 0 Alteration Permit El'iocotdTtoviow. 0 Temporary Housing <br /> El Major woe: QOther 0 Connecting to an Existing System Never`in Use <br /> (IWO .- old) <br /> Quic1—:.p1oto Specify <br /> . „ <br /> Ift40',"itlgitOiffe0 and attachments are not included witliiiiiisTapplieciitoit„:iewill be'returned to you as incomplete; <br /> Post the orange,card tiweatraneeto the propertr, Flag Maud-holes: <br /> By my signature,;I:certifylhat the information!have fwitishe4 is correct;:and Ileretiy,grant Mitkien4scptiAty;aailiorite.4-4geatvf,the. <br /> DePailiuent.ofEmxronniental Q044,permission to enter onto the above described property for the sole purpose of this#01ie4tibn, <br /> CAY-15—i414+04. '50;-4t4 -321 <br /> Applicant s Name-Please Print Legibly Aotioanrs=m00mobqr- DEQ Lic # 00010101.0 <br /> • .Po* 4tY. tortoluAtitttl Sf._ Se SaIan ote Conwal-f-: Zakvietto.t_, <br /> :Applicant imaiiii444000 Email61730Z <br /> %LlAkt riziog <br /> Siimatiiro .CCBg (If applicable) <br /> tp-r,Ps://mARICNCOUNTYWC-IvEYSHAREPOINECOMVERSONAIJBREICHSO-MARION'OR OS/DOCUMENTS/DESKTOPS-01,ONSITE APPEAULY. <br /> ::;024-0y724.r.pcx <br />