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g\-t: _o_cA28 <br /> Application for Onsite Date Stamp: <br /> ;=�� : Wastewater Treatment System RECEIVED <br /> MiMARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION SEP 04 2024 <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.ns/PW/BuildinzInspection <br /> r - 0 _.,_..�..._"it_MMte _ 7770,�,:;.::.- ,-...aa ri_, - - - <br /> c ) ®�5 '�t,Ven 1m2 4� <br /> Name 3 Mailing Address <br /> \e. be -q (—i a Li -7 <br /> City,State,and Zi¢, o (Area Cod Phone#_ <br /> Property Address City State / Zip Code <br /> Parcel# , Tax Lot Acreage or Lot S. <br /> j L <br /> L- <br /> Dir to,. ;operty: t W 2-2- " ��T" Pd.- GM'eS- 1 L pot <br /> Zvip-i Ld- - on sate e - + <br /> � Cam, t,� <br /> : ''' u gh'ari ra seaG Ta ' r ut"o rafi'on;.- t_ ... <br /> E ' i1 _esidential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: t <br /> I \It' ^^ \ ubfio <br /> O/i ... ma/ Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ <br /> Seating Seating 0 privafe <br /> Well,Spring,Shared <br /> WW1*tir—AFP � _..— ��. vL` 4.-.....SE:X J ..J. .._Y.�-.v . <br /> "".-ar...+r+-d--+-:-.a---..�....re..�.--.:Y.:.�L:. • ...,' '.._���y -'-.. .� _. �= -- <br /> ❑ Site Evaluation 0 Renewal Permit uthorization Notice for: <br /> �� ~�� <br /> ❑ Construction Permit 0 Permit Reinstatement [ lacing a Dwelling <br /> 0 Repair Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> 0 Major 0 Minor ❑ Existing System Evaluation , ❑ Personal Hardship <br /> 0 Alteration Permit ❑ Record Review 0 Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other 0 Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 0 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 /> (ld inn G-,a Got bocAr/ 51 63) W f- f3 L 7 <br /> Applicant's Name—Please Print Legibly App icant's Phone Number DEQ Lic.#(if applicable) <br /> i0 s <br /> 5Lock'h. 4R /0uvt-N -kekZ r?6 e3 . <br /> Applicant's Mailing Address 1 I �4 f „vial I, Cow) <br /> m-- Cab 1 f�5f (4- <br /> gna 41 Date: CCB# (if applicable) <br /> HTTPS://MARIONCOUNTYGCC-MY.SHAREPOINT.COM/PERSONALBREICH CO MARION_OR US/DOCUMENTS/DESKTOP/S-01 ONSITE APPL JULY <br /> 2024 REV 7.24.DOCX Rev 1/15,3/18,6/22,6/23— <br /> N <br />