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g3 -Mid 11 <br /> Application for Onsite Date <br /> .al °jna� Stamp: <br /> Wastewater Treatment System <br /> imi,,,, <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION l'EC.-E[M <br /> 5155 Silverton Rd NE II SEP 01 2023 — <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 MARION COUNTY <br /> www.co.marion.or.us/PW/Buildinglnspection BUILDING INSPECTION <br /> A Property_Owner.Information ; , <br /> I6CNT)rt-sy'LA) 3A2A Ai`i C Z5- \\R-tiL) \4AJe0 (2. <br /> Name Mailing Address <br /> r'cL,ta ikk Die- 01 3) 7 <br /> City,State,and Zip „ . _._._ (Area Code)Phone# -- <br /> B.Legal Property Description l <br /> q 2s- tvcc 3 7(1- 5 L.cc.11/4"... (!c 9-1 3Z S <br /> Property Address City State Zip Code <br /> 0-7a wZD oc)0100 \ i 1_"7 A--e_424. s <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property:F(" OI Cora- vim 21 To Rti E tk of C 1.ic€Sz. 5T r TUt2k) Nohe-T%-k 00 1.7C.00 <br /> rgtte-N <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> ❑Public <br /> ?j J 4 I-,f ,-1- f A Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees! ® Private W L-1,—. <br /> Seating Seating <br /> Well,Spring,Shared <br /> D.Type of Application _._ __ � _ ____ __ _a a _ . .:_.rt _ .-._. : __ __ _ e _- _ <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> El 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 El Personal Hardship <br /> El Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major El Minor El Other El Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> El 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 /> n <br /> l IDAA( 0.55 l mtnalkvc 4 ov- i 1-1-e- (5-03) S-7A - 3E CO -39 2G Lf - <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic. #(if applicable) <br /> pc.0, `3ox `(L02_ ,A v r,,s.l ► t, D ,7 3 a �,sscuv�c.✓.e,-(c cot►54r6�f.�^cO ,�,re.,pe."-. <br /> Applicant's M ' 'ng Address Email: <br /> etrnSZ q <br /> gnature Date: CCB# (if applicable) <br /> Applicant is the ❑Owner ®Authorized Representative(form attached) <br /> G:\BUILDING INSPECTION\FORMS\SEPTIC\S-01 ONSITE APPL JULY 2023 REV 6.23.DOCX Rev 1/15,3/18,6/22,6/23 <br />