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Application for Onsite <br /> Date Stamp: <br /> Wastewater Treatment System ® [ <br /> MARION COUNTY PUBLIC WORKS d 11 MAY 0 8 2024 <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE MARION COUNTY <br /> Salem OR97305 BUILDING INSPECTION <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/BuildinzInsoection <br /> S°Progertg{(3vvaerYrn ormahoa r <br /> ,4 , e /41e4 s J c ® . �c //6/ <br /> Name �/ Mailing Address <br /> 5-17vek/ti ae. 173D - 916 - 7 <br /> City, State,and Zip (Area Code)Phone# <br /> :Legal:spropert►iDcription <br /> /96 90 ///nE <br /> Property Address / City State Zip Code <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: u j 4/1/ /vel o<//c bury ,Ao ,/f/�,�✓g 7/c,G Ze.A ex/4 r'q hi <br /> C.Es" Fa X{gro Deed,FaQ7rtv'C, rfi _- <br /> ,.� .v.._. 7, <br /> �stiug_,cilrtg.,� , p �atecI�formatiou s. .. . ,_ . . ��..:_ �.:.� - .� <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/ r 4 private ktiGll <br /> Seating Seating <br /> Well,Spring,Shared <br /> 4 D T%pe'of'Appluahoaf y n -?nr r N;, u - r r _ <br /> ❑ Site.Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> jg Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> El Major El 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 /> Ate,,/ G' s-c53--9/0- 3 ,l <br /> Applicant's Name—Pleasent Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> ��- 1#42.e( �l �r>�/{�� �- �1�38f aarewrievacc, G74AO' cv" <br /> Applicant's Mailing Address Email: <br /> ature Date: CCB# (if 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 />