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4/--.006)5 <br /> 1147. <br /> (9, <br /> w> <br /> Application for Onsite RECEIVED <br /> Wastewater Treatment System <br /> JAP10 91014 <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> m v.co.marion.onns/PW/Buildip_zInspsction <br /> A.Property Owner Information 11737 <br /> ). ) TA v�ea-,vntct$ 11137 ki NkAuk LN <br /> Name Mailing Addr <br /> D IV\ DK, 0.�353 SU3-Saar go <br /> City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> �V = vi Wk.5 Ni;Is t3 ik trADN5- <br /> Property A ress City State Zip Code <br /> OCtiAd4A8 o no Sot oil. kue <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: 0 tf i Yt f O w' Y\ YNek f t, "&(\Q k/1(1 ek <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> ['Public <br /> Lts Name;�. SeG) <br /> Number of Bedrooms Number of Bedrooms Number ofEmployees/ Number ofEmployees/Seating Seating Private U'�p� <br /> Q II <br /> Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation 0 Renewal Permit ❑A thorization Notice for: <br /> • Construction Permit ❑ Permit Reinstatement al Replacing a Dwelling <br /> 'i%4e.air Permit ❑ Permit Transfer 0 The Addition of One or More Bedrooms <br /> �t1, Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> A t`ration Permit ❑ Record Review ❑ Temporary Housing <br /> . Iv Major ❑ Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> l (over 5-yrs old) <br /> 0 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 /> Ir►� S0tri 5.O3 S( Lto 7 38co(-)�l <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic. #(if applicable) <br /> 7.--7g 1-1-wq 22(0 o d P--_ 973-7LI lit) )40E84/ 0_5.41-- /111✓T 4i4. <br /> Applicant's Mailing Address Email: <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the ❑ Owner ❑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 />