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<br /> ci. 6b ( 5
<br /> Application for Onsite D4te,Ot1TP RECEIVED
<br /> _.„.,..,„.
<br /> Wastewater Treatment System
<br /> JUL 02 2024
<br /> "MAR ION COUNTYPUBLIC WOW-
<br /> ' EUILDINGINSPECTION DIVISION
<br /> 5155Silverton Rd NE
<br /> Salem..OR;97.305
<br /> 0031-588-5147 lar-(503).588-7948
<br /> -www:comarion;or.us/PW/Builclinginspection
<br /> 1.i'AtrdklirOt **Af*n4AOAnte-z2i:-5wiksf,i;,:fe-fLm7r-;',,:,n%',:itwfzzu,--ui-;'::::- ae:*:- 54'
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<br /> % :.:. , . . . . ,.- ,. .
<br /> 1/10 akkCebl .1q.cgcra Winorteyvt1
<br /> .
<br /> : . ;. Die-
<br /> Mailing
<br /> Address
<br /> Oree\ C\At1 ORCr01 34431 .
<br /> cw„ :ta,t .;.4414 Zip_ (Area-Oade).Phonel
<br /> kVek4ffiiii4#.0.i41*.tt*fb;':I. . . . TT112:P,•;;.:Rit.7:,-Vif:',E
<br /> a0t1S tAantriVi 'R..veht:RA.H. S.,-.6 ,cfline)..m.s.:_. : og. :91,57, ..s..
<br /> :Property Addre.4 .City State: Zip:-Code
<br /> •CA,g.': 00
<br /> ... - . -
<br /> Parcer4' Tax Lot ACreage.or Lot Size
<br /> Directions:to Property:
<br /> ??6,-tilS'tingillOrtolOsid-FaillitY1*iferlifil'irinatin.i,;7A-7,5 -::.-
<br /> Existing Residential: .Proposer!Residential •Existing Commercial Proposed Commercial. Water Simply:
<br /> :Publics
<br /> Name
<br /> ,
<br /> - ' lo
<br /> Employees/ Number ofEM
<br /> of
<br /> pyeed (tIr - iVP-.t 1.". - ' A 9
<br /> NMtber ofirectrborag Number. Niiinber:OfBerlrooms ' geadii :Prrvate,k '4:.. I SPY":.0-.-.
<br /> g g
<br /> Wel4.:Spting,Shared.
<br /> 34',.7::: iitAkiiiiitfOlitil---'1'.----:"'1'1 %.:,•:::.'-,: i.-.-`: :''•:'4:ii!'----'3'`.;T"f". :... -1.4 :Z..-Al :L-:,'41,!:;:::..ii,A .,. .aiii7,:;: -'1]#I2I.'L'A"'13a.t;i4i14.
<br /> ite:El:fain-anon. 0 Renewal Permit 0Apthorization'Notict for:
<br /> Construction Pernik 0 Permit Reinstatement 0 XepI4641g,411:11irouilig:
<br /> El Repair:Permit la Permit Transfer 0 The Addition of One More Bedrooms
<br /> El Major 0 Minor .0 Existing System Evaluation Ei Personal:EOM*,
<br /> t1 Alteration Permit Er Record Review El Temporary Housing
<br /> 1:[ Major D Minor 0 Other Ei Connecting te an Existing System Never in Use
<br /> '(oty.eryia414).,
<br /> - Other,-Please SpeCify'
<br /> Ifihe:regzikoptfe .417401401*020.47.*i.*Ii#etriete4"*44:(.his:rappliceitiott;it will'fiereturneditaympaginCarksgege..
<br /> PbsVille.iorange card atl.b.d.eritraned tii.theftotkriY: Flag the test holes:
<br /> By signaturei,--teertifythattheitifOrMatien I li#0:forniabedisOerreet,and hereby grant Marion County authorized of the
<br /> Department of Ethdronmental-QoalityPeriniasiento enter onto the.above'described-property for the,sole..purpose of this application.
<br /> Tra41 Lt:act- ,AD$ :93S.-Ta61-34.pp saat-up.
<br /> . . .. .
<br /> :Atipli:c44..SNSfrie-,Pre Print:Legibly Applicant's Phone Ntimber DR/tic:cif:(if applicable).
<br /> .3:01 a., liwil cgiS tYibltikt.a Og. 1161.-- Cg "tea aoshiz corli
<br /> Applicanes Mailing Address. . Email::
<br /> .cv0,611fundija 6,' 1 I.Q.,1t4
<br /> $
<br /> ' -•
<br /> . ., :
<br /> rgnature:- ' • Date,
<br /> . . CCE# (if..apPlioaKe)
<br /> •IITTPgt/iMARIONO9ONT-YdOc4.17r. 17.COrifipRSONALIBREICH CO. .rvigt.RION:OR tt/DOCOMOOS/DESKTOP/R=01 ON,SITEAPPLWf
<br /> 2024.REV7:24-.DOCX Rev:1115;:3/1:8'...617.2,443-
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