|
023- bDS-1°10
<br /> Application for Onsite
<br /> Wastewater Treatment System 1D EC - '" E ni
<br /> awl- JUL 10 2023
<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/BandingInspection
<br /> LL4=ReauersAW vnerInfotllig#,Ok.L.Z:'LL
<br /> riVej \AJ il lams tb‘ ' ' -760 acrarr. Iviril ) :Put
<br /> Name
<br /> Mailing Address
<br /> .C:11k Mitk Og q-1570 c1-7 I - -7/8'-3-ncl ,
<br /> _City,,State,and. ,4iT) _ __m _ __„ , * (Area Code)Phpnefi 1:15B:iLtiairtifirektNeSeia**34:, 7:',V,';.,- .',,,t::--''''',107-7:77t-O-tt.f.x,::-.:1•;-',-,2:‘,L,:',:a'..",,':: 7.,: ''',',-,:.-2,.77-7,77,--' :'-';'-7737777 :71
<br /> ..,.,....,—....._,_ ...,_,......„
<br /> 7IC() C—FrarttliirlOAkie._ —C-:4" Kiln
<br /> Property Address- City State Zip Code
<br /> bb 5oCI
<br /> Parcel# Tax Lot ACerealgeca7LoCit(7Siz—le , 75
<br /> Directions to Property:
<br /> /;•>• °'JE7 it stinirFairliti-itirniiosed-FaCili#IWaterinfOrmatioir x.'
<br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Sup ly;
<br /> 2.-
<br /> Z- Public 16
<br /> ?
<br /> NI of of Employees/ Number of Emoloyees/ 1-1
<br /> Number of Bedrooms Number of'Bedrooms
<br /> Seating - LI Priv
<br /> EC*iit.-AiilliiiarOT17:::T:-T:7-7::''--7-.'II;-„LTLZ,,E;,ijir7sM7rF:F777757:77 1Vat:eCN11::-;:::7:it:s:are74s
<br /> 0Site Evaluation 0 Renewal Permit 0.4thorization Notice for:
<br /> Ini Construction Permit 0 Permit Reinstatement , Replacing a Dwelling
<br /> N. Repair Permit ' 0 Permit Transfer ID The Addition of One or More BedrOoms
<br /> git IGrajor 0 minor El Existing System Evaluation 0 Personal Hardship
<br /> 0 Alteration Permit 0 Record Review .. 1:1 Temporary Housing
<br /> El Major El Minor 123 Other `rtS--1-• 1.--it-s 0 Connecting to an Existing System Never in Use
<br /> (over 5-yrs old).
<br /> lAt_Led (,), '2g.,..'ff%./T-V,Lbo 0 Other—Please Specify
<br /> If the required fee, ' •.'i achments are not included with this application, it will be returnedto you as incomplete.
<br /> Post the orange card at the entrance to.the property. Flag the test holes. 1
<br /> By my signature,I certi4i 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*cis application.
<br /> veggieLl€. c) 3q2-57--
<br /> ChokrteEenreil-(-Fennell asPil, *e- - ,- -Lii-iSz ' '
<br /> Applicant's Nanie—Please Print Legibly Applicant's Phone Number DEQ Lic. #(if applicable)
<br /> 170 55'1 I tiflolakIcx OR c1-740 %-- befyin-cf-k-.-p4i e,S9rv'' isfelia.
<br /> Applicant's Mailing Address
<br /> Email: g7n120.0 ?
<br /> Signature Date: CCB# (if applicable)
<br /> Applicant is the 0 Owner ..RrAuthorized Representative(form attached)
<br /> GAMILDING INSPECTIONTORMSISEPTIC14.701 ONSITE APPL JULY 2023 REV 6.23.DOCX Rev 1/15,3/18,6/22,6123 A449-6-4
<br /> 7.71--)-5 6. -01/05..
<br />
|