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it <br /> Application for Onsite Date Stamp: <br /> Wastewater Treatment System <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 /> www.co.marion.or.us/PW/BuildingInsoection <br /> A.ProPerty owner nformati9n,.: , <br /> (F//47S ✓ ;e1�tizi.A 'O� / �641.._ PA. Mg, <br /> Name Mailing Address <br /> — S 44 E `'% , V D! .503 6s6 q' -76q'2 <br /> City,State,and Zip (Area Code)Phone# <br /> B <br /> 23c3 t/ s,1A,7 M w Ett YON 117 3S ' <br /> Property Address City State Zip Code <br /> Eafeeh-#- 'Tax Lob <br /> Directions to Property: <br /> C Eg�stin Facih Pro used Fae�h /„Water-Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms Numberng Seat of Employees/ Numiberng of Employees/ Pri e <br /> Seati <br /> Well,S ring, Shared <br /> D Type of Apphoutsit , ,. _u_ � • <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 /> ❑ 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 bard 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 /> his 14 06713,4tV 6-02 ^ �67r 7( <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> �03 A Pi N.t <br /> Applicant's Mailin Ad Email: <br /> d4- ag <br /> 6 - 2 z/ <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 AUGUST 2024 REV 8.24.DOCX Rev 1/15,3/18,6/22,6/23,8/24 <br />