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;4- <br /> Application for Onsite Date Stamp: <br /> Wastewater Treatment System <br /> .111111 MARION COUNTY PUBLIC WORKS RECEIVED <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE AUG 2 8 2024 <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/BuildingInspection % \el <br /> I A.Property__Owner:Information L . ...,,, Aw. '.� C QIQ,, <br /> -� eAchIS ?D X ' 77‘ <br /> Name" <br /> am Mailing Address <br /> - / C ���5 sz3 - 97 - V O? <br /> City,State an Zi Area Code Phone# <br /> B Legal Pro_pertiy-Description � ,-..� . �-- ' .. ,n .. ,,, :- '.,,. <br /> 1006V 5l e�J A,j ast- •1 C �� <br /> Property Address✓ City , State Z p Code <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> C.ExistmgFacilii../,ProusedFacility/Water1.for'.mation'..: , ,, , -, . :1 <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> tc. <br /> _ , DPublic <br /> Name <br /> ivumber o Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ P e <br /> Seating Seating <br /> Well ring,Shared <br /> I .Type of Application_ ::_— _.._ 77 --_` _.._ __ti - —__ 'z <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 Bedroom•% <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ►' 'ersonal Hardshi. <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 /> rye A, � i4o/c S3—97 — yG1-g <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> 3 <br /> ii GR �� e sn ccols 4.,,a/ , fa j <br /> Applicant�ddress / G Email: <br /> -�i�-t O ',�--��L/ <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 AUGUST 2024 REV 8.24.DOCX Rev 1/15,3/18,6/22,6/23,8/24 <br />