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024-stibeD15a <br /> Application for Onsite Date Stamp: <br /> �- Wastewater Treatment System 1!1\41 <br /> � ��mo.......-4 <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISIONMAR19 201#5155 Silverton Rd NE <br /> SalemOR97305ARIONCOUNTY(503)588-5147 Fax(503)588-7948BLDING INSPECTION <br /> www.co.marion.or.us/PWBuildin2Insnection <br /> 1.ve.�..A.., � ..a. .Z r xx�^ T p .q,.«...< ......"'� i - '."e-'2 _A`d. a i <br /> 27C:Property Owner informahii _.M1._. .�.�. _3 . �..-.''. ,: ..._ .� _ a. . -.v : —....�,...w. �.v. --,.. . °1 <br /> Lk t, c -,0 /\i /14 �� ?cciy (, , fo Box I210 <br /> Name ) Mailing Address <br /> 1ir - OR 9 73 f� 50 3- o - 9- 3/ <br /> City,State and Zip_ (Area Code)Phone# <br /> Eli"HIegal PropertyDescription . w_w a.�, .-::.... .ww._.._£ ,...M w. ,...._�._... Z �, <br /> 7,73 <br /> 5//9- //f/L'N;ould,,- rA 5P ~.� OP. 7,7.'r7 <br /> Property Address City State Zip Code <br /> (Y W POW «"� ':�1)4'7 f%%, f► 0 <br /> Parcel# Tax Lot Acreage or Lot Size <br /> f i <br /> tonn <br /> Directions to Property: jil.54". v �,R. -ffat Y{ c.(0033, 'Z ►+ 112. 0►-. 11......4,k✓- Rai. <br /> t:Existing Facility/Proposed Facility/Water Lformation., W N` 777,L:,sT7ZTF-7-7-77771 <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> I-1- OPublic <br /> Name <br /> Number of Bedrooms Number of Bedrooms Seating of Employees/ Number <br /> mbe of Employees/ X Private .L f <br /> ating <br /> Well,Spring,Shared <br /> D NType of Apphcahon 7:7a._.a�.,,.. ...�.: .._ w._. .:: ..:7,74 ._.._...: ..777771 �. M�..d1 <br /> 1 Site Evaluation 0 Renewal Permit ['Authorization Notice for: <br /> Construction Permit 0 Permit Reinstatement 0 Replacing a Dwelling <br /> ❑ Repair Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor 0 Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit 0 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, itt will be returned to you as incomplete. <br /> Post the orange card at the entrance to the property. Flag the test holes. V <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 /> L .,_ cWi rc& co 7 -9 30-993 I <br /> Applicant's Name Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> ?o Loic 12,0 1 - - Q 0t77 l-�t rcki SI /, & <br /> Applican' M 'ing Address Email: <br /> ,A7-2-.07 <br /> ignature Date: CCB# (if applicable) <br /> Applicant is the Owner ❑Authorized Representative(form attached) <br /> G:\BUILDING CTION\FORMS\SEPTIC\S-01 ONSITE APPL JULY 2023 REV 6.23.DOCX Rev 1/15,3/18,6/22,6/23 <br />