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2 y-00g70 / PZkA1 <br /> Application for Onsite Date Stamp: <br /> • <br /> Wastewater Treatment System <br /> MARION COUNTY PUBLIC WORKSECEOVI3 <br /> -� <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE J U L 02 2024 —J <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 MARION COUNTY <br /> www.co.marion.onus/PW/Buildinglnspection BUILDING INSPECTION <br /> A.Property Owner Tnformati .__._ . . ' :x r 4 - <.a <br /> 5't/ �roe,bv Z�2 14 s4 <br /> Name Mailing Address <br /> 5 -' !fr1Je, off. 9'734 '03 7(0 —07 iSO <br /> City, State,and Zip (Area Code)Phone# <br /> B Tlegal Pr'operxy description • w , ��.., _ _L__w n._ <br /> a f,ceh Ce_m4/ 5.'1ve.fiv ' et_ 7 �tr/ <br /> Property Address City State Zip Code <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> C.E sting aciIity f Propased Facslity/'Water Info ahonu ye _.w.w. ,....!. <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/ <br /> Seating Seating ❑ Private <br /> Well, Spring,Shared <br /> � ' pe:of Appircation <br /> ❑ Site Evaluation ❑ Renewal Permit utho ization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement :u eplacing a Dwelling <br /> Nov Re it Permit <br /> ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> El 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 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 /> 5.41, , c—i 3 -7/0 77r <br /> Applicant's Name— L'lease t Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> LG <br /> `e Pi 51 1/.e(4-•01 ,V if 4Si , I <br /> Applic s Mailing Address ` mail: <br /> Co <br /> GG ,� <br /> ignatur Date: CCB# (if applicable) <br /> Applicant is the frOwner ❑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 />