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(9q-51)Latb) <br /> Application for Onsite Date Stamp: <br /> ----. ;� ;, Wastewater Treatment System <br /> 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/BuildingInsuection <br /> A Property,OwnerInforn ation _._..,. .. ..w._..,_. A <br /> ect vve -CEAD( (0� �S .,, bilAs Irve boa./ <br /> Name Mailing Address <br /> Sad Q 0CZ 9---7 (1 .5039-3 i CS <br /> City, State,and Zip (Area Code)Phone# <br /> L_.,_ . __ �_. ... <br /> 41 co s SCkvts�tih-e Way U 9-731-2 <br /> Property Address City State Zip Code <br /> P ZeebCot Acre / <br /> Directions to Property: 4lM \5\J c 11-e -F\cO U' -s q_ )e1/Y\ "Ft" p(r- <br /> uv� Sktn-t? LAD <br /> C Existing Facfiity/,Proposedac�htyy./WateInfocanon j <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> 6reig: ❑Public <br /> Name <br /> Number of Bedrooms umber of Bedrooms Number of Employees/ Number ofEmployees/ 14 <br /> P va <br /> Seating Seating <br /> We 1, Spring, Shared <br /> D TypeofAppltcaaon _. .,_.. ,_ __....._, �.... <br /> El Site Evaluation ❑ Renewal Permit authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement /// ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer The Addition of neWt Bet s <br /> ❑ Major ID ❑Minor' Existing System Evaluation Personal Hardship ��}}66{{�`pp�` <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> El Major ❑ Minor ❑ Other ❑ Connecting to an Existing System Never m e <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 /> y 503 ��,� bZ)'� <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> pp 'cant's Mailing Address 1 Email: ��V��VJJJJ <br /> \-1 I <br /> S. a e D te: /A CCB#(if applicable) <br /> •ppli .it is the ['Owner Autho ' d Repr tative(form attached) <br /> G:\BUILDING INSPECTION\FORMS\SEPTIC\S-01 ONSITE APPL AUGUST 2024 REV 8.24.DOCX Rev 1/15,3/18,6/22,6/23,8/24 <br />