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77 3 --00 7/ 2 3 PP/A i <br /> Application for Onsite <br /> Wastewater Treatment System <br /> Ti <br /> MARION COUNTY PUBLIC WORKS . 15.93 3 22 2g23 <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE IOARION COUNTY <br /> Salem OR 97305 rzl DING INSPECTION' <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/BuildingInspection <br /> A.Property Owner Information <br /> P1 ili'p c(yes 776'3 J�cKson fall Kd_ S E <br /> Name Mailing Address <br /> &devil 0 17304 363- 777-4/44> <br /> City,State,and/Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> 7783 J cKson fill) Rd.. 5E Salem... OR. 7734 <br /> Property Address City State Zip Code <br /> 7® <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ 141 Pri <br /> Seating Seating <br /> Well,S ring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit DAuthorization 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 /> ►l Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> Major ❑ Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> El 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 /> PhtltJ� &yes 503— 7%9-4/66 . U72N <br /> Applicdt's Name—Please Print Legibly Applicant's Phone Number DEQ Lic. #(if applicable) <br /> • 7783 Jackson 4-1 i l l get . SE safety, bR `P13 06 hilipthayesC�amczi l.cam <br /> Applicant's Mailing Address Email: <br /> ✓ ' 4 8-16 ✓ GV2.3 <br /> Signature 1.i Date: G�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 />