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r 23 - 0-0 9c4'3 gl`-�v 1./ <br /> ,; Application for Onsite Date Stamp: <br /> • ,T..--v Wastewater Treatment System E c i m <br /> MIMARION COUNTY PUBLIC WORKS <br />= BUILDING INSPECTION DIVISION OCT 3 ) 2 ''3 <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 MARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 BUILDING INSPECTION <br /> www.co.marion.or.us/PW/BuildingInsoection <br /> aA.Pupa Owned;tnl ogmat►on ±M iEi ' ...,.. .'. s , <br /> e / v' vds[�r_fl,. pa, asb <br /> NamMa MailingAddress <br /> 5C0f1. /A't;/!5 . q737,5 <br /> City,State,and Zi (Area Code)Phone# <br /> r eegal Property:Deseription. :a, b . ° .�...1,.. <br /> f K.rivo_51*ie)V, iver'/# <br /> 11, <br /> a_e_ <br /> / is. Lo <br /> Property Addres City State Zip Code <br /> c 7 d 6evu <br /> 4---, <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> C::. x stir ,FaciliW/Wiiposed Fae tytWateil ifuxniatiOir :. Z''' .w,.. ,. -sli k, <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> 1Public <br /> Name <br /> Number o Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ <br /> Seating Seating ❑ Private <br /> Well,Spring, Shared <br /> D Type of Application •.r r .. .. <br /> ❑ Site Evaluation El Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> 12 Repair Permit ❑ Permit Transfer El The Addition of One or More Bedrooms <br /> 'g Major ❑ Minor ❑ Existing System Evaluation El 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 /> <et Ia'c+lt v,‘ LLC, 6.63- s 7I -3 Ono - g SY-1-0- <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> 2 0( )r okI k Rot , jJ. , ScIc 0r,9 7303 Atk<c-c IPA ) vt4.4. I z6OM <br /> Applicant's Mailing Address Email: <br /> 4c_1- 1 30 fZO23 21c3$ 7 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the El 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 />