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13--- c/L3 9 Pturit
<br /> Application for Onsite r
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<br /> - '--,, Wastewater Treatment System D F C [ep_ vE 0
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<br /> 1viAR10N co1JNT''PUBLIC wOItl=;s _ 111 ? 9n^�
<br /> BUILDING INSPECTION DIVISION
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<br /> . 5155 Silverton Rd NE
<br /> Salem OR 97305 MARION COUNTY
<br /> (503)588-5147 Fax(503)588-7948 BUILDING INSPECTION
<br /> Gk_ww.co.in:.i oai_01.:.u /PE_s`114.oiitil milltsDsctio7.
<br /> A.Property Owner Information
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<br /> Name Mailing Address
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<br /> City,State,and Zip (Area Code)Phone#
<br /> B.Legal Property Description
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<br /> .ter.._,; . I s•Vr! '' r Asa °' - `'.. tr' •! •.1`Pv�`'`.` ^' tr p l fit' .»' f
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<br /> Property Address 1 City State Zip Code
<br /> Parcel# Tax Lot Acreage or Lot Size
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<br /> ` � ' c r\ `.1 ': 4 ar. ra �' kDirections to Propert • r l�'i.t ,, .: . ,,,,I..,
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<br /> C.Existing Facility/Proposed Facility/Water Information — - c - �>•
<br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply:
<br /> e n� ['Publica c.4, A4Y Itti Name
<br /> Number of Employees/ Number of Employees/
<br /> Number of Bedrooms Number of Bedrooms Private,
<br /> Seating Seating .,.
<br /> ti Well Spring,Shared
<br /> I).Type of Application
<br /> I, _,Site Evaluation ❑ Renewal Permit ❑Authorization Notice for:
<br /> ❑ Construction Permit 0 Permit Reinstatement 'Replacing a Dwelling
<br /> ❑ Repair Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms
<br /> 1 0 Major ❑ Minor ❑ Existing System Evaluation 0 Personal Hardship
<br /> ❑ Alteration Permit 0 Record Review ❑ Temporary Housing
<br /> 0 Major 0 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 /> Department of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application.
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<br /> P[ i rl' "rr_-' 1, C`,, ` t,.^ ^fir?. C
<br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.'#(if applicable)
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<br /> Applicant's Mailing Address Email:
<br /> Sig tore< r. Date: CCB# (if applicable)
<br /> Applicant is the U. Owner ❑Authorized Representative(form attached)
<br /> G!.BUILDING INSPECTIONIFORMS\SEPTIC\S-01 ONSITE APPL JULY 2023 REV 6.23.DOCX'Rev 1/15,3/18,6'22,6/23
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