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Application for Onsite Date Stamp: <br /> Wastewater Treatment System ® ! C E 0 V <br /> MARION COUNTY PUBLIC WORKS <br /> A II is <br /> BUILDING INSPECTION DIVISION - PiA4 08 2on ---J <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/Buildinglnspection <br /> A:Property Owner Information Plat-Les <br /> l lG 11 1."h ,� 1- ,/�v.�t 5 � /Z 16 (a. IZ0 g <br /> Name Mailing Address <br /> 5,1L.ftlir4--% C512 ` -7S�1 GO3- �lI 62� <br /> City,State,and Zip 1 (Area Code)Phone# <br /> • <br /> B:._IJegal:PopertyDescription <br /> 166 I tct-t _s IUL 0 v- ' --- 3�11 <br /> Property Address City State Zip Code <br /> C3 ) (w Z—i&OOO'Z'u1 '706 6 1 <br /> Parcel# Tax Lot' Acreage or Lot Size <br /> Directions to Property: <br /> C Existing•Factity/;Proposed Facility/Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> 6 ['Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees! Number of Employees/ Private Ik/ i'/ <br /> Seating Seating <br /> Well,Spring,Shared <br /> D:;Type of-Applicatio_n• , <br /> ❑ Site Evaluation El Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit 0 Permit Reinstatement - 0 Replacing a Dwelling <br /> gj Repair Permit 0 Permit Transfer ❑ The Addition of One or More Bedrooms <br /> El Major El Minor El Existing System Evaluation El Personal Hardship <br /> ❑ Alteration Permit El Record Review El Temporary Housing <br /> El Major ❑ Minor ❑ Other El Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 0 Other—Please Specify <br /> gee let."... EY,o�c� t't� S�5� /AdafLrc,,nSe+-t hi__ <br /> 15,-i pleVsF 'f*t4d- W6S riveLvt$Ly cc-Ali-tee-lee(7Yt /SI f°7a1 <br /> If the required fee and attachments are not included with this application, it will be returned to >ou as incoinplete. t ��+u-ge <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 /> Oregon Sewer& Drain LLC 503-874-9414 38968 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> PO Box 1282 Silverton, OR 97381 josh@oregonsewer.com <br /> Applicant's Mailing dress Email: <br /> S 201683 <br /> Sign re Date: CCB# (if applicable) <br /> Applicant is the 0 Owner IN 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 />