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ay`b1- 11 <br /> Application for Onsite DateStim,: <br /> —_ Wastewater Treatment System <br /> �' RECEIVED <br /> MARION`COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION JUN 212024 <br /> 5155.Silve.rton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> www:co.ma rion.or.us/PW/Buildinalnspection <br /> IclA'Property Owner Information <br /> i Clvt Clotn1a Ara b i(ALin <br /> Name Mailing Address <br /> City,State,and Zip (Area Code)Phone'# <br /> B.:Legal•Pto a., tiara -; - i <br /> B flyDescri, <br /> ..... P ; <br /> \ — l t 14. tCMV\ (,U'1 tA,c:", \c t) VlCM/ _ q7c Z <br /> Property Address City State Zip Code <br /> J litYLe.COQ 11'0 000#60 /. Coac, <br /> Parcel# Tax.Lot Acreage or Lot Size <br /> n <br /> Directions to Property: <br /> C Existing Facility/Proposed Facility/Water IfiforMation'::':: _ . <br /> Existing Residential: Proposed Residential: Existing.Commercial: Proposed Commercial: Water Supply: <br /> _ ! Ill <br /> /r 'I ❑Public <br /> Name <br /> Number orBedrooms: Number of Bedrooms Number of Employees/ Number of Employees/ ,I) <br /> Seating Seatiiag A Private p ,1. <br /> Well,Spring,Shared <br /> D.::T e,of_ location <br /> YP App . <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for <br /> Construction Permit. 0 Permit Reinstatement. ❑ Replacing a Dwelling. <br /> Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major 'Minor 0 Existing;System Evaluation ❑ Personal Hardship <br /> 0 Alteration Permit 0 Record Review 0 Temporary Housing <br /> ❑_Major 0 Minor 0 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 1 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 /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ'Lic.#(if applicable) <br /> f (tz31 re e' _ ( , e., lc`r` i'+ •k a.Co,;>ti, <br /> Applicant's Mailing Address mail: <br /> pignat.....,/,..01._ COA 7NC, <br /> ure Date: CCB## (if applicable) <br /> fiTIPS://MARIONCOUNTYGCC-MY.SHAREPOINT.CONf/PERSONAL/BREICH CO_MARION OR_GSiDOCUNIENTS t1ESKTOP/S-01.ONSITE APPL JULY <br /> 2024 REV 7.24.DOCX Rev 1/16,3/IS,6/22,6/23 <br />