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Application for Onsite <br /> Date Stamp: <br /> —�,.,- Wastewater Treatment System 24-co3orc0-Pt 'I <br /> MARION COUNTY PUBLIC WORKS RECEIVED <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE APR 18 2024 <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> wvvvv.co.marion.or.us/PW/BuildinzInsnection <br /> T.` ProperEY_O vner Information ` 74. ri 3_,._ _._._..3_._. , .._.7 _..._... ._, , A <br /> Q StrA Ji(rev (QcNei) , ictC04. C of�,e,& fill k& 9 <br /> Name Mailing Address <br /> H‘N\zoortl t'R\ •cytt:s so.1116 .'C00 1 <br /> City,State,and Zip (Area Code)Phone# <br /> B`LegalrPruperty,Descriptron 5 r <br /> qS \ "fin-es k�Ak)corA dk , ° i o <br /> Property Address City State Zip Code <br /> Parcel# . Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> t t _Egypt ng—El CIillty r.t C tg n �,. r ' .1 ..F� <br /> �Pra used Fa /=Water?InforniatioII ;� <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: _ <br /> OPublic <br /> S Name <br /> Number of Employees/ Number of Employees/ <br /> Number of Bedrooms Number of Bedrooms <br /> Seating Seating private <br /> .pring,Shared <br /> :? 5 PF`fi £ .f ! 31 ., r 7 - .,, r1 .� r: '' Y" Yx''C i s ti <br /> D :11T. t]f,APPliCat10II t ti :t3 w n <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ../2,.Construction Permit 0 Permit Reinstatement 0 Replacing a Dwelling <br /> 0 Repair Permit 0 Permit Transfer ❑ The Addition of One or More Bedrooms <br /> • ❑ Major ❑ Minor 0 Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review 0 Temporary Housing <br /> ❑ Major ❑ Minor 0 Other 0 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 /> ?ave,( 5neoffe l <br /> Applicant's N —Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> \° oO 2 nes A� CrNs‘0 14,i ng 4) '/Q�,00 'CQ�, <br /> Appl' is Mailing Address Email: <br /> \ -. <br /> Signa Date: CCB# (if applicable) <br /> Applicant is the ,]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 />