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Application for Onsite D E C E -Da StaE <br /> C Wastewater Treatment System <br /> �.� - AUG 0 9 2013 <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION MARION COUNTY <br /> 5155 Silverton Rd NE BUILDING INSPECTION <br /> Salem.OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/BuildingInspection <br /> A.Property Owner Information. <br /> Name Mailing Address <br /> City, State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> Property Address City State Zip Code <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> • <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ D Private <br /> Seating Seating <br /> Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ 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 Environmental4213[0i0 <br /> Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> c tO - ( a7.3 7g3— c/'3 0 y Applicant's Name—Please Print Legibly Applicant's <br /> Applicant's Phone Number DEQ Lic. #(if applicable) /j <br /> gc/� �GLku,1 Al e i lvA Gl oG � Jerivt r(?�3O2 ` 2 t��mU�t-/awis co�- ,com. <br /> Applicant's Mailing Address Email: <br /> g/9/2‘3 <br /> Sig a Date: CCB# (if applicable) <br /> A ii nt is the JOwner ❑Authorized Representative(form attached) <br /> G:\BUILDING INSPECTION\FO S\SEPTIC\S-01 ONSITE APPL JULY 2023 REV 6.23.DOCX Rev 1/15,3/18,6/22,6/23 <br />