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Application for Onsite Date Stamp: <br /> ',,, 2� CCU S t V 1•1 <br /> ---'—. ; , Wastewater Treatment System C <br /> MARION COUNTY PUBLIC WORKS <br /> AicE [IV .--- <br /> BUILDING INSPECTION DIVISION ___/ <br /> 5155 Silyerton Rd NE J U L 16 2024 <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 MARION COUNTY <br /> www.co.marion.onus/PWBuildingInspection BUILDING INSPECTION <br /> A.Pro a Owner Inform ation = <br /> . <br /> Name Mailing Address <br /> 5-1-4/40 A_ oectnv 9-0-i. .q10 2 6 0-3 <br /> City,State,Ind Zip (Area Code)Phone# <br /> B Leal Pro a Descri tion <br /> Property Address Ci yt State Zip Code <br /> z 1 c&scoop <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> C_Exishng Faciht-y/Proposed Facility 7;Water Information ._„ r ,, <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 76 Private 60-1-i i e, <br /> Well,Spring, Shared <br /> D7 a of A lication <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 ❑ Existing System Evaluation ❑ Personal Hardship <br /> O Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> 0 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 /> 1,4 C-1475:024.- -1::1<CAAg4)1-10 IA 5-6 . Cis2-8-i,MC- l' '.Z, ‘ <br /> Applicant's Name P� o <br /> Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> 1402.-14 , <br /> r7 kki-l-e.x_ eti„of4.7‘06149oLD 1 .e..otet. <br /> Applicant's M -ing Address Email: <br /> i.,,,‹ 7- \ - 7.0-7,--k( 2 4 crqr <br /> Signature Date: CCB# (if applicable) <br /> HTTPS://MARIONCOUNTYGCC-MY.SHAREPOINT.COM/PERSONALBREICH_COMARION_ORUS/DOCUMENTS/DESKTOP/S-01 ONSITE APPL <br /> AUGUST 2024 REV 8.24.DOCX Rev 1/15,3/18,6/22,6/23 <br />