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0911-Do 5d7q Application for Onsite Date Stamp: �;�_v Wastewater Treatment System 111111 MARION COUNTY PUBLIC WORKS 15IF—C " E BUILDING INSPECTION DIVISION 5155 Silverton Rd NE JUL 10 2024 Salem OR 97305 (503)588-5147 Fax(503)588-7948 MARION COUNTY www.co.marion.or.us/PWBuildingInspection BUILDING INSPECTION A.P iiig O.wn rnformRat bitZ,a_.: ,. 4-'z Zix .... ;A. :- 4>. LLII' mla ._.... .__ , , a PAL,cJ06, mAgiA c, '� P PQA' I$93& g,is teville RGl !dE Name Mailing Address Al t, L C i` :/ , -- Auto ra Olt 170422. 171 _ 506 - ©9q3 City, State,and Zip (Area Code)Phone# FALiia1 iiii D escri hon, ,¢ , _ . , i ii, Bur 'f"ev;iie Rd. NE Ato ra OR 97 oo 2` Property Address City State Zip Code U4-IW30G 00700 goo .5; OZ acre Parcel# Tax Lot Acreage or Lot Size Directions to Property: C Etstfii t'aciliti roposed Facile './.Wate ttfor-mation.>>3- ,, . ,,� 6 Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: ['Public Name Number of Bedrooms NumbePof edrooms Number of Employees/ Number of Employees/ 21fPri Seating Seating , Well, pring,Shared LI} e IAPphcatiolY,.: l ' 1,1.. .1;1 .2 ...a r,>F ,:°i: is - e , ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: igConstruction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling Repair Permit 0 Permit Transfer ❑ The Addition of One or More Bedrooms ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing ❑ Major ❑ Minor ❑ Other ❑ Connecting to an Existing System Never in Use (over 5-yrs old) ❑ Other—Please Specify If the required fee and attachments are not included with this application, it will be returned to you as incomplete. Post the orange card at the entrance to the property. Flag the test holes. By my signature,I certify that the information I have furnished is correct,and hereby grant Marion County,authorized agent of the Department of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. PA/AL- .00K15 SO - 979-62213 39757 Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) i lZl K'>�i e 4/ 1�e„ 5 Turner (>R �a id ere d -a o%k„Cd it A ' ant's Mailin ddress if 1739'Z Email: -`&44g: 7J 5 toy 21/37 Signature Date: CCB# (if applicable) Applicant is the ❑ Owner Elilthorized Representative(form attached) G:\BUILDING INSPECTION\FORMS\SEPTIC\S-01 ONSITE APPL JULY 2024 REV 7.24.DOCX Rev 1/15,3/18,6/22,6/23 ,