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Application for Onsite ate Sta <br /> pgmr <br /> ---� Wastewater Treatment System DECEIVE <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION �`IOV ® 9 2023 <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 I1�gRION COUiNTY <br /> (503)588-5147 Fax(503)588-7948 BUILDING INSPECTIOI�i <br /> www.co.marion.or.us/PW/BuildingInspection <br /> p <br /> A Pro e - OwnerInformation <br /> - ' <br /> l a 6 I) toslove..S 6 2G I 0.1.—ro o e j ad ./r/,-- <br /> Name Mailing Address <br /> .S1. e4,wt1 0/2 I '7 (3 7 (S03) ?36 - 3v/IDS <br /> City,State,and Zip_P (Area Code)Phone# <br /> B._Legal.PropertyDeseription <br /> /0o12, C4404reta xi A/r _A bidet a OR I?00a. <br /> Property Address City State Zip Code <br /> Parcel# Tax Lot Acreage or Lot Size <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 Bedrooms Number of edrooms Number of Employees/ Number of Employees! Private G✓) <br /> e <br /> II <br /> Seating Seating <br /> Well,Spring,Shared <br /> D.Type of_Application = <br /> ❑ Site Evaluation El Renewal Permit ❑Authorization Notice for: <br /> Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ElRepair Permit - El 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 /> El 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 /> fife. :-r'C, N1(41 g X C LLB -r6 3-32 9 Sc7c7 3 tj 4 <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic. #(if applicable) <br /> 67 A' f rr4 A"%- lel ti� IX c i'�zc�,_n <br /> App want' aili g Addres Email: <br /> 0 MA 7/2-3 / (fliq <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the El Owner cuthorized 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 />