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1 ogli- CO a)DID <br /> Application for Onsite Date Stamp: <br /> ,,,N, Wastewater Treatment System <br /> 1D ECEINED <br /> MI <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION 1 J U N 28 2024 <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 MARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 BUILDING INSPECTION <br /> www.co.marion.or.us/PW/BuildingInsnection <br /> A Property Owner Information <br /> , i,ase IV1,W/i 5g7 SE Aril- 5-/-, <br /> Name Mailing Address <br /> 60%krt1;41. 4R et73 g5 6-63-5 5 q 1126 <br /> City, State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> 1 01 > Fern Rt 4llr. Rot 7-ta i-o4 OR q736 3 <br /> Property Address City State Zip Code <br /> Parcel# Tax Lot Acreage or Lot Size _ • . <br /> • <br /> Directions to Property: <br /> C.Existing:Facility%`Proposed:Facility I Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> 3 ['Public <br /> Name <br /> Number of Employees/ Number of Employees/ <br /> Number of Bedrooms Number of Bedrooms Pnva <br /> Seating Seating <br /> .pring,Shared <br /> D.. Type of Application <br /> ❑ Site Evaluation 0 Renewal Permit E thorization Notice for: <br /> 1 ❑ Construction Permit ❑ Permit Reinstatement [f Replacing a Dwelling <br /> ❑ Repair Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> O Major 0 Minor 0 Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit 0 Record Review 0 Temporary Housing <br /> O Major ❑ Minor ❑ Other 0 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 Mark4County,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 /> e,afG Al C ri ) 5- ' 5-5'9 *—' '2 S <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> 5,7 SE i4rLa,- S Solil:A'I,;yr OR '173gS c%se✓.rncj;/I&nwha.4-meAl. can" <br /> Applicant's Mailing Address Email: <br /> G p/ �4 e/27f2°V <br /> Signature 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 />