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Le <br /> Application for Onsite Date Stamp: <br /> Wastewater Treatment System <br /> MARION COUNTY PUBLIC WORKS RECEIVED <br /> BUILDING INSPECTION DIVISION ���� <br /> 5155 Silverton Rd NE SEP 2 5 <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/Buildin2Inspection <br /> FA Property':Owne Thformation .__777,.. „__ ..... ._.__ . .. _ µµ <br /> Nfrsi QP'fr -2) 7t Q 1MmPa Ai 14.66 asp-,_ <br /> ame Mailing Address <br /> .Sig 1. r b 9i°3o 5z 3 S f`" '2 i c <br /> City,State,and Zip (Area Code)Phone# <br /> S Legal Property Description.,-, a.. �._. ?I; ._ : — <br /> %YZ 644 Xiltoti j4lLL 24 SE rn 6'Z. 9')33a C <br /> Property ddress City State Zip Code <br /> 1L, 4Iftlj166LIT' <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> Cam, .Existing;Facili' ,'!Pro"used FaciIiiy/Water.I'nformation <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/ private we/ <br /> Seating Seating ItS <br /> Well,Spring,Shared <br /> D Type.afApplicaon <br /> i k s <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit El Permit Transfer 0 The Addition of One or More Bedrooms <br /> ID Major ❑ Minor Existing System Evaluation V& Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major El 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 Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> 'atey'Z Alril t) hit LC RD SI_ SAth ®Q 79,30 1 ha.rn ,JR,,7oi 9>2 , com <br /> Applicant's Mailing ddre$&. Email: <br /> - 0 9 - 2®Z <br /> Signature Date: CCB#(if applicable) <br /> Applicant is the 'Owner ❑Authorized Representative(form attached) <br /> G:\BUILDING INSPECTION\FORMS\SEPTIC\S-01 ONSITE APPL AUGUST 2024 REV 8.24.DOCX Rev 1/15,3/18,6/22,6/23,8/24 <br />