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Application for Onsite o?L/bO36/6 - T <br /> Date Stamp: <br /> Wastewater Treatment SystemEC1 <br /> VED <br /> 11111 MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION MAY 0 3 2024 <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/BuildinEInsnection <br /> A.Property Owner Information <br /> <e�1i lr‘ L. 111Aekl 09 S T?4/le rr e- )Zd? SE <br /> Name Mailing Address <br /> .calms, v j cn3/ 7 S'03 - `fS - ar3 <br /> City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> () / C ) ��1e ere e t *Dr SE On- .07J17 <br /> Property Address City State Zip Code <br /> o f9 S 3 \,✓a c4 Boo/3eo -7 <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 /> Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees! Number of Employees! 0. Private J$di <br /> Seating Seating <br /> Well, Spring, Shared <br /> • <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> El Major El Minor El Existing System Evaluation ❑ Personal Hardship <br /> ,,Alteration Permit El Record Review ❑ Temporary Housing <br /> Major El Minor ❑ Other ❑ 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 /> 5'4)3 - 93A" 1lsO 3 7 5 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> 7 ci l Ale. 5 f 'I/-c ice 1'Ze'r, ® Ft 9-7 3o) WeIa,•1`q/c,r- <br /> Appl' ant's M ' ing ddress Email: <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the El 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 />