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r <br /> Application for Onsite <br /> Date Stamp: <br /> Wastewater Treatment System 1 <br /> MARION COUNTY PUBLIC WORKS RECEIVED <br /> BUILDING INSPECTION DIVISION 5155 Silverton Rd NE AuG 0 6 2024 <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/F'W/BuildingInspection <br /> A eProgert Qw� riaaho <br /> .Dpoccfylits Rr Woot'(ey 27200 S, Grihb�c= Red-. <br /> Name Mailing Address <br /> Canby, OR 970/3- S6-82 C 63) 781-35 99 <br /> City, State,and Zip (Area Code)yhone# <br /> A ; e 1 Pr petty_Description <br /> /4O '2 Pp�;- S1 NE /Iaral^ct OR 97002 <br /> Property Address City State Zip Code <br /> oil W02.DC O200d 561713 ..2 01- F925 Sr Ft, <br /> Parcel# Tax Lot-4 Acreage or Lot Size Directions to Property: Hlukharrd l uto'lirRd.. /a ma -era. AirpaFfCoded *Wiver /txt-n_Da e (Jed"Oh Pre - �f <br /> C E stm ,Fa-i .Y Pro ,used Facility I WaterxInfarmatian <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply:San5S- NNAven <br /> EiPublic z er• AssoeiaAyr- <br /> Name <br /> Number of Bedrooms Number OfBedrooms Number of Employees/ Number of Employees/ ❑ Private <br /> Seating Seating <br /> Well, Spring, Shared <br /> D T e of A hcatipn w . <br /> ❑ Site Evaluation ❑ Renewal Permit w A thorization 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 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 /> .Douslas R. W or.//ey (s03) 7J/-3599' <br /> Applicant's Name-Please PrinfLegibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> 27ZgO S, Grrhdle i &, Canhyr OR d17413- COo6lleyPdous G Omar/COM <br /> App ' ant's Mailing Address Email: <br /> le(ICJ, <br /> l� <br /> Si ature- Date: CCB# (if applicable) <br /> Applicant is the ® Owner ❑Authorized Representative(form attached) <br /> G:\BUILDING INSPECTION\FORMS\SEPTIC\S-01 ONSITE APPL JULY 2024 REV 7.24.DOCX Rev 1/15,3/18,6/22,6/23 <br />