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2'- CO 13 6 0 ?(zM1' <br /> ..„ ,, Application for Onsite •„IY <br /> %;_�� Wastewater Treatment System <br /> 1!!CI V <br /> MIMARION COUNTY PUBLIC WORKS FEB 16 <br /> BUILDING INSPECTION DIVISION 2024 <br /> 5155 Silverton Rd NE MARION COUNTY <br /> Salem OR 97305 BUILDING INSPECTION <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/BuildineInsuection <br /> A.Property Owner Information <br /> 5enty\_ 3 A`l U rn (oh rcf \d t &cS <br /> Name Mailing Address <br /> S-r. Pcual OR 9 713 '7 so3 - wog-- as 69 <br /> City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> ')o703 . SI. p I oR q 7/? 7 <br /> Property Address City State Zip Code <br /> Parcel# Q Tax Lot Acreage or Loto Size <br /> Directions to Property: R WQ PA 1 ST• fQJ. ``e�i on g l C lLY. (0 v}� <br /> 0,I k . Le ct oY\ R pert‹,i Df NE. Go 3A y1 Z Le_, on )4+1 <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> 0 3 OPublic <br /> Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ Private <br /> Seating Seating ;g <br /> Spring, Shared <br /> D.Type of Application <br /> Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> Construction Permit El Permit Reinstatement ElReplacing a Dwelling <br /> Repair Permit El Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other ❑ 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 oran eg 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 /> ?eg% <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> KO VJ/Jrvas - 503-32/ -Sz.o 7 <br /> Applicant' ailing Address Email: <br /> ` 0-/‘- .7 / • /C/ 9 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the Owner ❑Authorized Representative(form attached) <br /> G:\BUILDING INSPECTIO O S\SEPTIC\S-01 ONSITE APPL JULY 2023 REV 6.23.DOCX Rev 1/15,3/18,6/22,6/23 <br />