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4- L1b5 <br /> Application for Onsite <br /> Date Stamp: <br /> Wastewater Treatment System s <br /> E��� . <br /> MARION COUNTY PUBLIC WORKS REC <br /> .70 <br /> BUILDING INSPECTION DIVISION AUG 23 i4Lk <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> wvvvv.co.marion.or.us/PW/BuildingInspection <br /> A.Property Owner Information <br /> 1. &A E (7(5 M 'L;M 'RD. N.£. <br /> Name Mailing Address <br /> L.v_rOl4, OR-€604 g7 503 - 580- Zs 39 <br /> City, State,and Zip (Area Code)Phone# <br /> B.L gal Pro erty Description <br /> M i &t4 14.e. siLVegrb1,1 D q 7331 <br /> Property Address City State Zip Code <br /> .Pareell mot ge or <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 Employees/ Number of Employees/ <br /> Number of Bedrooms umber o Be rooms Seating Seating ate <br /> Well pring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit uthorization 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 /> tI ? B f_ 503 - 5-M -25 3 q <br /> Applicant's ame—Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> (0765 1`-1 ibis Vb. 1\1. E.. '23. KB SS NAIL •Coi <br /> Applicant's Mailing Address Email: <br /> A41i�� -22-� / <br /> 2 <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 JULY 2024 REV 7.24.DOCX Rev 1/15,3/18,6/22,6/23 <br />