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,,, Application for Onsite Date Stamp: <br /> Wastewater Treatment System <br /> • <br /> MARION COUNTY PUBLIC WORKS 613- 6b.8 1 11 <br /> BUILDING INSPECTION DIVISION ® C E P �J <br /> 5155 Silverton Rd NE v <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 d SEP 27 2023 <br /> www.co.marion.or.us/PW/Buildinalnspection <br /> MARIO <br /> COUNTY <br /> A Property Owner.•Informahon :,. . ,.. . - :_.. ^ BUILDINGr IN INSPECTION <br /> AAL0A/ h/ l 5n6 3 frect iNvos � <br /> Name Mailing Address <br /> 0lA/&ia 0J q73 ') 006 3Y8 V 81 <br /> City,State,and Zip I r <br /> (Area Code)Phone# <br /> B Legal Property`Descnption' = <br /> 15 D 63 I- igti tirris £ ##- S'`/f/ev „, OK ? 7 df <br /> Property Address City State Zip Code <br /> Parcel# Tax Lot - Acreage or Lot Size <br /> Directions to Property: l . l - m Per fir'. 44/1c, LA <br /> C Existwg Facil ty'I 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 ofEmployees/ Number ofEmployees/ rivate <br /> Seating Seating <br /> ell, pring,Shared <br /> D T ' of Apphcat on . .. :_ ,: __ - <br /> Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> 0 Major ❑ Minor 0 Existing System Evaluation 0 Personal Hardship <br /> O Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> 0 Major 0 Minor 0 Other 0 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 /> ( rtl�P n�-rl a# I. <br /> So3-4.A3=4 <- 3.33)( <br /> -(nnli�ant's Nine—Please Print Apnlicanf's Phone.Number _ DEQ Lic. #(if applicable) <br /> /? "/ S (, e,A s-I- ' i a/k /PE' 97.��rf -. �y�/. 71,!`��e �'l/ . in <br /> Appl'cant's Mailing Address m$1l <br /> 'w� <br /> Si a re G3' '-- Date: CCB# (if applicable) <br /> Applicant is the ❑Owner ❑Authorized Representative(form attached) <br /> G:\BUILDING INSPECTION\FORMS\SEPTIC\S-01 ONSITE APPL JULY 2023 REV 6.23.DOCX Rev 1/15,-3/18,6/22,6/23 <br />