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bo 5 1-13- R1Yrr <br /> Application for Onsite Date Stamp: <br /> _--- �= Wastewater Treatment System RECEIVED <br /> 1111111 MARION COUNTY PUBLIC WORKS 2024 <br /> BUILDING INSPECTION DIVISION • <br /> JUL 12 <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/Buildinelnsnection <br /> A,.Property Owner:)Inforri> Lion �p <br /> Ck 's E11(T 3 si) -7g4 /1vV.e e- <br /> Name Mailing Address <br /> Set bum D 9") 3 17 sal - 36- ?'Z5-Y <br /> City,State,and Zip (Area Code)Phone it <br /> B.;Legal Property Description.;_; .. .. <br /> 3°I5 4 SC 1 6K q73i7 <br /> Property Address City State Zip.Code <br /> 16 z /1 <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> C.:ExitingFacility I,Proposed;Facility t Water.Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> 3 ['Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms Seating of Employees/ Number of Employees/ �rivate �e.r <br /> eating <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 /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> Alte on Permit El 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 he 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 /> -ti3a S`f <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lie.#(if applicable) <br /> 39 ?`3 n <br /> s� zySC )ejL,„„, 61r` 6173i7 enaelli3Qw za -eLL' <br /> Applican ailing Address Email: <br /> a- !( I Zhr <br /> Signatur Date: CCB# (if applicable) <br /> HTTPS://MARIONCOUNTYGCC-MY.SHAltEPOINT.COM/PERSONAL/BREICH CO MARION OR US/DOCUMENTS/DESKTOP/S-01 ONSITE APPL JULY <br /> 2024 REV 7.24.DOCX Rev 1/15,3/1 S,6/22,6/23 <br />