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S90 <br /> EVE <br /> Application for OnsiteDate Stamp: <br /> Wastewater Treatment System <br /> � AUG i 9 2024 <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503).588-7948 <br /> www.co.marion.or.us/PW/BuildingInsnection <br /> 4: yPrope y Owner Infornrahon .......4 <br /> „i l am. /t i1 V, eleyeelL ak. <br /> Name Mailing Address <br /> City,State,and Zip (Area Code)Phone# <br /> B egal Property Description ;; <br /> Property Address City State Zip Code <br /> 0- I E 6.61 oo 136O G 1300 <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> C E stingy ac IitV/,,tProposed Faulty I WaterInform ation° *. <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 Sg ® Private kliel( <br /> Well,Spring,Shared <br /> ;D e b Ah i s h yx <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit 0 Permit Reinstatement 0 Replacing a Dwelling <br /> cgi Repair Permit ❑ Permit Transfer 0 The Addition of One or More Bedrooms <br /> 0 Major; RI Minor 0 Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review 0 Temporary Housing <br /> ❑ Major 0 Minor ❑ Other 0 Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 91g L2c le . H ❑ 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,T certify that the information I have furnished is correct,and hereby grant Marion County,authorized agent of the <br /> Department of Ervironmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> Oregon Sewer& Drain LLC 503-874-9414 38968 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> e <br /> PO Box 1282 Silverto OR 9 3 1 josh@oregonsewer.com <br /> Applicant's Email: <br /> -`( 201683 <br /> nature Date: CCB# (if applicable) <br /> Applicant is the. " ❑Owner PS]Authorized Representative(form attached) <br /> G:\BUILDING 1NSPECTIONIFORMSISEPTIC\S-01 ONSITE APPL JULY 2023 REV 6.23.DOCX Rev 1/15,3/18,6/22,6/23 <br />