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•• —, <br /> - . <br /> . , <br /> Application for for Onsite 0.0 Ramp• <br /> . —411172.1r: Wastewater Treatment System 02 q, 61;1'5835 <br /> OM. <br /> ____—. MAR EON COUNTY PUBLIC WORKS <br /> ........_ . <br /> BUILDINC INSPECTION DIVISION RECEIVED <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 JUL 2 6 2024 <br /> (503)588-5147 Fax.(503)588-7948 <br /> wv+w.co.inn rion.oros/PW/BuilditigInspeeti9.11 <br /> A.Property Owner Information <br /> -De..4a_r_ili 6 ar_l_ ...0 kat._ 1-1_,, -7-1-0 . • <br /> Name <br /> Mailing Address <br /> -101atra.Ktik_, ,.. 5-0 _ <br /> City.*State.and Z ip <br /> (Area Code)Phone if <br /> B.Legal Property Description <br /> (4 CVA-113 N. SaA:67„4,-‘ 441,0{..\ tcbtriko, ' o V_ ')- -1St - <br /> Property Address. -.) City State Zip Code <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information' ' ' <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial:: Water Supply: <br /> DPublic • <br /> 2 Name <br /> ofEmployees/ Number of Employees/ <br /> Number of Bedmorris NuMber of-Bedrooms Number• 0 Private <br /> Seating: Seating <br /> Well,Spring,Shared <br /> 11.Type or Applicaiion : .- . ,, - <br /> 0 Site Evaluation 0 Renewal Permit OAuthorization Notice for <br /> 0 Construction Permit ,0 Permit Reinstatement 0 Replacing a Dwelling <br /> Er-Repair Permit ' 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> 0 Major Eri/finor 0 Existing System Evaluation O Personal Hardship <br /> 0 Alteration Permit 0 Record Review 0 Temporary Housing <br /> 0 Major 0 Minor 0 Other , 0 Connecting to an Existing System Never in Use <br /> (over 5+-yrs old) <br /> 0 Other=Please Specify <br /> If the requiredfee and attachments are not included with this application, it will be returned to you-as incomplete.. <br /> Post theOrange card at theentrance to the property. Flag the test holes. <br /> By my siguature 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 /> ' &Ar.___D Name eixon: 503- 8gq- 672-1 (49 1347 lei 1 <br /> App• 's lease Print Legibly Applicant's.Phone Number DEQLic.#(if applicable) <br /> -P.O. €ov C21-ce • ' . 5 <br /> Applicant's Mailing Address ' ail: <br /> Cavi-p <br /> _ <br /> ii:41‘.. &-i-------:•--- 7/1 5/24 2 11 I-I 1 <br /> Signature Date: CCB# (if applicable) <br /> HITPSNMARIONCOUNTYGCC41Y.SRAREPOINT,COM/PERSONAL/BREICH_CO_MARION_ORJA/DOCLIMENTS/13ESKTOP/S-01-ONSITE APPL JUL Y <br /> 2024 REV 724.DOCX Rev 1/15,3/18,6/22,,6123 <br /> , <br />