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„q .,, Application for Onsite. Date Stamp: <br /> =2=- Wastewater Treatment System <br /> i MARION 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/Buildinglusnection <br /> A.Property Owner Information <br /> NC--S�cwtcGS 4gtio s„� No s° mwr -wD - <br /> Name Mailing Address T <br /> I <br /> Vitit.SoOV4t-t-E O °Flailb 9-13-12q-7(0,oct <br /> City,State,and Zip 1 <br /> (Area Code)Phone# <br /> B .Le al Property Description <br /> -) 65 utLo6gv.N( L J, <br /> SAtEt•n OR etno11) <br /> Property Address City State Zip Code <br /> ‘100 C P lAk 1 083w1CaDoorio0 13Qw W. S <br /> Parcel# <br /> Tax Lot Acreage or Lot Size <br /> Directionsto Property: SS S O\J \ 'co D A05�Frc- 1 DC--14 LJC-S`C To 4,ki1,1-Decwwy LiJ, ow <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 Prime wE w • <br /> Seating Seating <br /> Wei Spring,Shared <br /> D.Type of Application: . <br /> isa Site Evaluation • 0 Renewal Permit ❑Authorization Notice for. <br /> ❑ Construction Permit 0 Permit Reinstatement 0 Replacing a Dwelling . <br /> ❑ Repair Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> ❑ Major 0 Minor 0 Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review 0 Temporary Housing <br /> 0 Major 0 Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 0 Other—Please Specify <br /> lithe 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 /> Atu a,o Col\kce ( . S63=11s%-3(42.8G1 NlA <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> 1-0,14 Sw laaMSSISWG-ft—M.t VALS+01,3V4t.1.5 talk ° 10')0 ACSt-itSIlCGS.MA1>.0,6MA4L.um, <br /> A ' is ' Address Email: <br /> (Q11”1, - . <br /> Signature Date: CCB# (if applicable) <br /> C:\USaRS1AN CHFZ\APPDATA\LOCAL\MICROSOFINWINDOWS\IIVETCACHE\CONTENT.OUTLOOK\FI L2DXINS-01 ONSITE APPL JULY <br /> 2023 REV 6.23.DOCX Rev 1/15,3/18,622,6/23 <br />