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- 3b1gi51 IQ <br /> Application for Onsite Dt6CEIVED <br /> Wastewater Treatment System <br /> AUG 02 2024 <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/Buildin2Inspection <br /> A Property Owner Information : . . • <br /> G 0 a_m C k 2-1 F(2-9 g- <br /> Name Mailing Address <br /> Ct1QO23 - 17 zfo—344( 3 <br /> City,State,and Zip (Area Code)Phone# <br /> LcgalProPert-Oeseitip_tion ":: 2:- , <br /> I 2_1 2-2 F(2-Lt (2 0115-: A cia_orZ-X Property Address Address City State Zip Code <br /> 411,3 alp-00 goo <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> C;Exis1ing FacihtyJ Piopoied'facilltYy Water Informaticm . <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> ['Public <br /> 3 biz- Name <br /> Number of Employees/ Number of Employees/ rfri, <br /> Number of Bedrooms Number of Bedrooms LAI private (,k) 1_1_ <br /> Seating Seating <br /> Well,Spring,Shared <br /> B Type of Application <br /> EL Site Evaluation El Renewal Permit IDAuthorization Notice for: <br /> El Construction Permit El Permit Reinstatement PUI Replacing a Dwelling <br /> El Repair Permit El Permit Transfer al The Addition of One or More Bedrooms <br /> El Major El Minor El Existing System Evaluation El Personal Hardship <br /> [::1 Alteration Permit El Record Review I=1 Temporary Housing <br /> 1=I Major LI Minor 1:] Other ID 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 /> 612t7 oce_el e 4(e 3 <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> 2..t 2_2- F12-cl /2-cA ) /4 urt_.c.924 ocE. 7c,c, LJA&Aia-r—C-05 7-0,-4 laid7/2/1A/1...„ <br /> Applicant's Mailing Address Email: <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the Owner I=1 Authorized Representative(form attached) <br /> HTTPS://MAR1ONCOUNTYGCC-MY.SHAREPOINT.COM/PERSONAL/BRFICH_CO MAR1ON_OR US/DOCUMENTS/DESKTOP/S-01 ONSITE APPL <br /> AUGUST 2024 REV 8.24.DOCX Rev 1/15,3/18,6/22,6/23,8/24 <br />