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c211--nbi 16\ <br /> Application for Onsite <br /> Date Stamp: <br /> uc <br /> Wastewater Treatment System <br /> MARION COUNTY PUBLIC WORKS RYMUVEn <br /> BUILDING INSPECTION DIVISION JUL 08 2024 pj <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 MARION COUNTY <br /> www.co.marion.onus/PW/BuildingInspection BUILL.'t INSPECTION <br /> A Property 0wnez 7nfarmahon <br /> !Abl Eam i k1 Ae, Pc 2 <br /> Name I Mailing Address <br /> #4 3 oe 6o;-6si,qvc <br /> City an, State, . ip (Area Code)Phone <br /> 'B I,cgaLPcopertyjescription__.w..,:. ._ �..,.M. .... . .._ _.. __�. �. �.�.. �< , ..u�_. � �� �. <br /> Ic�ii Ho `�WairLe. (� � 0h 9•7os <br /> Property Address City State Zip Code <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> vit <br /> \` i�'LOPublic <br /> Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number o mployees/ ❑ Private <br /> Seating Seating <br /> 5 <br /> 4.1 Ynoa�' -Spring,Shared <br /> r IY„ . 0 of A iplicatroa ..,._ � .........,:�_. , 77. )24uthorization <br /> IDSite Evaluation ❑ Renewal Permit Notice for: <br /> ▪ Construction Permit ElPermit Reinstatement . ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> El Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other El Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> ❑ 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 /> .,,- 503-551- LiZd <br /> Applicant's Name— •lease Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> CR/11 's a4n O lkw 1�6 lire An �173&" ' b Qr� Z@ llye <br /> App 'f:it's Ming Adiess Email: v <br /> 01/C6/2-aLi <br /> Signature ge: CCB# (if applicable) <br /> Applicant is the ❑ Owner Authorized Representative(form attached) <br /> G:\BUILDING INSPECTION\FORMS\SEPTIC\S-01 OE APPL JULY 2024 REV 7.24.DOCX Rev 1/15,3/18,6/22,6/23 <br />