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Application for Onsite Date Stamp: <br /> Wastewater Treatment System <br /> MARION COUNTY PUBLIC WORKS D C I II v <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE _ JUL 16 2024 <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 MARION COUNTY <br /> www.co.marion.or.us/PW/Buildinenspection BUILDING INSPECTION <br /> podal Pv vvt.... /44/. xtfileascup PO 3t91 <35-6 <br /> Name Mailing Address <br /> Sr, Aut OR.tGan 97/,57 5o3-76'o - 1z2V (sir4 <br /> City,State,and Zip (Area Code)Phone# <br /> , ��r�per�?�°�escriptiurt <br /> 62AI/31 K: efa Rd Ale Sr. aut. ezt 97/37 <br /> Property Address City State Zip Code <br /> god 7t , - <br /> Parcel# 2 Tax Lot t/ Acreage or Lot Size <br /> Directions to Property: 4tex .d m t 165 Ak 12414 f fYvG &�x r! /e! cg2 i8Cf <br /> ti on Wcss Z 1rie fie( <br /> C +�ttstmg 1 acrlit 1 Fr used aetll i Water lnfarmaiai z - .- <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/ p a e <br /> Seating Seating <br /> Well <br /> Prmg, Shared <br /> ❑ Site Evaluation ❑ Renewal Permit thorization Notice for: <br /> ❑ Construction Permit El Permit Reinstatement a eplacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major ❑ 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 infe•r ation I have furnished is correct,and hereby grant Marion County,authorized agent of the <br /> Department of Environmental Qua ,p-rmission to enter onto the above described property for the sole purpose of this application. <br /> pplicant's Nam- —Please ' t . 'i ly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> iR1i' /2-. - " ,�r�Z, ti4 q7257 /14,e6acz-_ mv/ 5g045 4 <br /> A 'cakt's Mailing A ess Email: <br /> /,-SAD L <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the ❑ Owner ❑Authorized Representative(form attached) <br /> G:\BUILDING INSPECTION\FORMS\SEPTIC\S-01 ONSITE APPL JULY 2024 REV 7.24.DOCX Rev 1/15,3/18,6/22,6/23 <br />