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Application for Onsite• DateStamp: <br /> --- Wastewater Treatment System <br /> riMARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/BuiidingIaasnection <br /> A;Property Ownerinformation <br /> Name Mailing Address <br /> VJtitS11 V1A-LE 6R °11616 Sal-11a-3C24ek <br /> City,State,and Zip t (Area Code)Phone# <br /> B.Legal:Property Description <br /> 1g �5. <br /> 1,JILDQC-.- SALMA o 913ot <br /> Property Address City State Zip Code <br /> 1 .S 3 O 0 eflt. .Cl 3) 093V1-( )Oo23o °1'$ ac fl S <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: IS 'SONG`\ "'G6 DCLili3S\/ DCt.A V,L=ST"TO VJLt•OQGr"(Ly <br /> 1SPV <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/ pg Private W E • <br /> Seating Seating <br /> We I Spring,Shared <br /> al Site Evaluation ❑ Renewal Permit ['Authorization Notice for. <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer 0 The Addition of One or More Bedrooms <br /> 0 Major 0 Minor 0 Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit 0 Record Review ❑ Temporary Housing <br /> ❑ 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 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 /> AWN GPkik96 S63=11-°►-3(118°1 N`A <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> Sw aeMss .DC-�r1.-cam. % V1 Lot 0Oo o Iskamilccs.MA1te6MML,.C,o , <br /> Ap es Address Email: <br /> (An\1-4 <br /> Signature Date: CCB# (if applicable) <br /> C:\USERS\ANAJERAS C}JEZ1APPDATA\LOCAL\MICROSOFIIW1NDOWS\INETCACHE\CONTENT.OUTLOOKIPKJL2D,c .o1 ONSrL t APPL JULY <br /> 2023 REV 623.DOCX Rev 1/15,3/18,6122,6/23 <br />