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2q/00(e706 P Mr <br /> Application for Onsite Date Stamp: <br /> --� ; :� Wastewater Treatment System <br /> MARION COUNTY PUBLIC WORKS D E C ! - V l 7 <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE AUG 23 2024 <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 MARION COUNTY <br /> www.co.marion.or.us/PWBuildingInspection BUILDING INSPECTION <br /> A Property.Owner Information <br /> 8; Hy s MA1'%+AdQ Pay kc✓° 8 35 NU Frcak 54. <br /> Name Mailing Address <br /> Sto Dh t445 , 4R cj73sS S63- 576 -97y9 <br /> City,State,and Zip (Area Code)Phone# <br /> mB Legal Property,Description .,. <br /> 1 20gt F). .ppy WA3 J ie Lrse., 6 n g7325 <br /> Property Address City State Zip Code <br /> O93wv./'Do0Ccob 2, zS <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: —±- 5 Soukk. 40 "ScAt.esor Hwy el9L Sk, 1r s1- o 14 S+eiwer- <br /> rcl s e. S.-frt. 4., W<pPy L)ij <br /> CC Existing Facility/Proposed,Facilrty L Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> ❑Public <br /> y / Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ 1R`j Private ‘A)C.Li ( ) <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. <br /> ❑ Repair Permit ❑ Replacing a Dwelling <br /> p ❑ 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 /> 0 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 /> DepartmentDe of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> / yI,r Gwr ... - g,.,ooie )rX.( 5°3-q'3 z-o '8y 3923 I <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> 86 zy gl.ckha,,a4 ci S6 ,KI,Orr E XCAVA7Io0 ,: ,aol. cow, <br /> Applicant's Mailing Address Email: <br /> ` ./�� L� 8 , z3 .2y 1 G SSYS <br /> Sign Lure Date: CCB# (if applicable) <br /> HTTPS://MARIONCOUNTYGCC-MY.SHAREPOINT.COM/PERSONAL/BREICH_CO_MARION_OR_US/DOCUMENTS/DESKTOP/S-01 ONSITE APPL <br /> AUGUST 2024 REV 8.24.DOCX Rev 1/15,3/18,6/22,6/23 <br />