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PH-6b \L\ a. <br /> Application for Onsite Date Stamp: <br /> �;�,1., Wastewater Treatment System <br /> mg, ® <br /> MARION COUNTY PUBLIC WORKS I ,C Er �/�/7 <br /> EB <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE J U L 03 2024 <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 MARION COUNTY <br /> www.co.marion.or.us/PWBuildinglnspection BUILDING INSPECTION <br /> A Property Owner Information _ _ 2 _ <br /> -3 0 5 \NlA_G--._ F06 0,,V'ill ‘D'' ° ' 5 0A 5 <br /> Name Mailing Address <br /> 5:\ 0 -V—ipti\ I op_ ,'-73 ,e s--c - c‘ •\ 0 - 7 3c) 1 <br /> City, State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> 1 LA 408 EVO,r5' (f Kl<<eo psME S ?\vev-*ur. , - 9732 <br /> Property Address City State Zip Code <br /> 15.73 <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> C Existing Facility/Proposed Facility/Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> ❑Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms Numbere of Employees/ Number of Employees/ _ rAiii privat- _ <br /> ating <br /> Well Spring,Shared <br /> D•Type of Application <br /> El Site Evaluation El Renewal Permit *Authorization Notice for: <br /> El Construction Permit El Permit Reinstatement ❑ Replacing a Dwelling <br /> El Repair Permit El Permit Transfer El The Addition of One or More Bedrooms <br /> El Major ❑ Minor El Existing System Evaluation El Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review El Temporary Housing <br /> El Major El Minor ❑ Other 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 /> dusk (---G k"(A— 5"O3 ^ CO0 -73c)q <br /> Applicant's Name—Please Pivint Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br />, P 6 . &63\pct5 5' , ‘ uei s6Dv-\, az- cteuei --F . , , <br /> 0 yls- 1,-,0-0a eiv,o.ci .L.0 ill <br /> Appl• ant's Mailing Address Email: <br /> Si <br /> ii,V.--- .<7 77 - L <br /> .IVIP. <br /> •igna lliP. Date: CCB# (if applicable) <br /> HTTPS: ••r1. ONCOUNTYGCC-MY.SHAREPOINT.COM/PERSONAL/BREICHCO MARION OR US/DOCUMENTS/DESKTOP/S-01 ONS1TE APPL JULY <br /> 2024 REV 7.24.DOCX Rev 1/15,3/18,6/22,6/23 <br />