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a otbLQI61-1 <br /> ; 1 Application for Onsite <br /> Date Stamp: <br /> := Wastewater Treatment System RECEIVE® <br /> MN , <br /> MARION COUNTY PUBLIC WORKS AUG02 Za� <br /> BUILDING INSPECTION DIVISION /1 7 <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> !www.co.marion.or.us/PW/BuildingInsnection <br /> A.Property Owrier Iaform it41 . <br /> 24A,, `f 4l,JGd/4 L tLI LizieN g6,e-Q. 4., 'E <br /> Name' ` Mailing Address <br /> cA , c vz 91 ( 5c3-z V3- 7l1'7 <br /> City,State and Zip (Area Code)Phone# <br /> B Lega)_Propeit}�Descnptton_ . ,:, - . <br /> i <br /> 176- asp . .Aft_ S 6- Se,.IX 0 �-r seA <br /> Property Address City State Zip Code <br /> (-✓ G 6 on /goo Igo '-Icce <br /> Parcel# Tax Lot Acreage or Lot Size - <br /> Directions to Property: <br /> ,c.;,:faititkit Facility IProposed Facility!Water:fnformatton .: <br /> Existing Residential: Proposed Residentia1:1 Existing Commercial: Proposed Commercial: Water Supply: <br /> ' pr. 15 ❑Public <br /> ', Name <br /> Number of Bedrooms Number of Bedrooms Number of Employe's/ Number of Employees/ <br /> �� <br /> Seating Seating EFI Private 1( --Plat; d <br /> P7 Well,Spring,Shared <br /> D Type of Applteatron. ; <br /> Site Evaluation El Renewal Permit ❑Authorization Notice for: <br /> Construction Permit 0 Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit, ❑ Permit Transfer 0 The Addition of One or More Bedrooms • <br /> ❑ Major ❑ Minor ❑ ExistingSystem Evaluation 0 Personal.Hardship <br /> ❑ Alteration.Permit 0 Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor 0 Other <br /> 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,f certify that the information jI 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 /> Oregon Sewer& Drain. LLC 503-874-9414 38968 <br /> Applicant's Name-Please Print Legibly Applicant's.Phone Number DEQ Lic. #(if applicable) <br /> PO Box 1282 Silverton. OR 97381 josh@oregonsewer.com <br /> Applicant's Mailin ddress Email: <br /> �'� 7 Z.1,/,- // 201683 <br /> atur Date: CCB# (if applicable) <br /> Applicant is the ❑Owner in Authorized Representative(form attached) <br /> G:\BUILDING INSPECTION\FORMS\SEPTICtS-01 ONSITE APPL JULY 2023 REV 6.23.DOCX Rev I/15,3/18,6/22,6/23 <br />