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(91-I-CO 02D
<br /> ,, Application for Onsite Date Stamp:
<br /> F�_ Wastewater Treatment System RECEIVED
<br /> ' ' 1 MARION COUNTY PUBLIC WORKS
<br /> BUILDING INSPECTION DIVISION APR 171024
<br /> 5155 Silverton Rd NE
<br /> Salem OR 97305 -
<br /> (503)588-5147 Fax(503)588-7948
<br /> www.co.marion.or.us/PW/Buildinanspection
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<br /> Name Mailing Address
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<br /> City, State, and Zip (Area Code)Phone#
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<br /> Property Address City State Zip Code
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<br /> Parcel# Tax Lot I Acreage or Lot Size _
<br /> Directions to Property: S o,4 f:,,.►rt /4(t)9 'l-o G-el 5 5e4::o lid 1 o f (.4 I- G.,p r,e C
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<br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: .
<br /> DPublic �
<br /> Employees/ Employees/ P 7 Li c1,cc
<br /> Name
<br /> Number of Bedrooms Number of Bedrooms Number of El / Number of
<br /> Seating Seating ❑ Private
<br /> Well,Spring,Shared
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<br /> at...Site Evaluation ❑ Renewal Permit ®Authorization Notice for:
<br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling
<br /> ` c ep it Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms
<br /> L ajor ❑ Minor El Existing System Evaluation ❑ Personal Hardship
<br /> ❑ Alteration Permit Record Review ❑ Temporary Housing
<br /> ❑ Major ❑ Minor ❑ Other Pa in if ❑ 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 /> vry IV ew(-0)1 5'03; 31- dc 1 3gl9b
<br /> Applicant's Name—Please Print Legibly Applicants Thone Number DEQ//�� Lic.#(if applicable)
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<br /> Applicant's Mailing Address Email:
<br /> 2 & Pad gJ Li
<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 DULY 2023 REV 6.23.DOCX Rev 1/15,3/18,6/22,623
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