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Application for OnsiteRECEHEB <br /> pp Date Stamp: <br /> lid <br /> Wastewater Treatment System k SEP 26 2023 <br /> MARION COUNTY PUBLIC WORKS MgRION COUNTY <br /> BUILDING INSPECTION DIVISION BUILDING INSPECTION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PWBuildingInsnection <br /> A.Property Owner Information <br /> 7441 LA; e I rIe/L 1:64 Lrf c6 <br /> Name Mailing Address <br /> City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description_ <br /> )a? iD b iv _V& 0R Q7 Ira <br /> Property Address City State Zip Code <br /> I Ir, 67 <br /> Parcel# Tax Lot Acreage r Lot Size <br /> Directions to Pro r : i one 'e: A- Or 1 lee.toox <br /> tt <br /> (sA 4-A t i e fee 11 ; flti•-• <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/ <br /> Seating Seating ❑ Private <br /> Well,Spring,Shared <br /> D.Type of Application • <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement El Replacing a Dwelling <br /> ❑ Repair Permit El Permit Transfer ❑ The Addition of One or More Bedrooms <br /> El Major ❑ Minor ❑ Existing System Evaluation El Personal Hardship <br /> EI .Alteration Permit El Record Review El Temporary Housing <br /> El Major [Minor ❑ Other El Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> El Other—Please Specify <br /> Ad l 11;: art v ar4Araor.. AQ 1.- �t a�cp <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 /> Applicant's Name—Please Priif Legibly Applicant's Phone Number DEQ Lic. #(if applicable) <br /> ev c —004 "Vitrawr oR 67°73t2_ o-p_Kc gal&i,c. (Gri, <br /> Applicant's Mailing Address Email: <br /> 4--et (1414/ q/-2,e/73 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the ❑Owner [il 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 />