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di\ -Gb\3a9 <br /> w., Application for Onsite Date Stamp: <br /> Wastewater Treatment System E c E [i v E <br /> imm, <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NEC 2n�24 <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 MARION COUNTY <br /> www.co.marion.or.us/.PW/BuildingInseection BUILDING INSPECTION <br /> A.Property Owner Informatioir. <br /> Jr 1 Lee,144Mg5 JEP', g1t51 13)/7 e64. e k lZaS <br /> Name / Mailing Address <br /> Sr I iiiii m, i afZ_ ei7S / 3 _get-,,,-- t a'-ziL <br /> City,State,and Zip (Area Code)Phone# <br /> S Legal,ProperGyDescription <br /> ,Z IV I 13-1,4 Ciez l&t rah Sp L1/wT•-. OR- `t-rg v l <br /> Property Address City State Zip Code <br /> ( ITO iA-ce,e)ci Lie.r_J r 'c' <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> C l✓aistrng Facility./Proposed;Facility I Water Information:.,. <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> 3 ['Public <br /> JIMI <br /> Name <br /> Number of Bedrooms Number of Bedrooms <br /> Number of Employees/ Number of Employees/ i_ 'e J <br /> Seating Seating ( Private Vt/ -t�I <br /> Well,Spring,Shared <br /> D Type of Application <br /> 0 Site Evaluation ❑ Renewal Permit ❑Authorization Notice for. <br /> aConstruction Permit El Permit Reinstatement ❑ Replacing a Dwelling <br /> Repair Permit ❑. Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major 0 Minor ElExisting System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review 0 Temporary Housing <br /> ❑ Major 0 Minor 0 Other ❑ Connecting to an Existing System.Never in Use <br /> (over 5-yrs old) <br /> >k rev- 5a—t ve.I r Atr. .fit /.Z_ ❑ Ocher—Please Specify <br /> lithe 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 nay signature,I certify that the information I have furnished is collect,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 /> , <br /> Oregon Sewer& Drain LLC 503-874-9414 38968 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lie.#(if applicable) <br /> PO Box 1282 Silverton. OR 97381 josh@oregonsewer.com <br /> Applicant' ir . ddr Email: <br /> A-dt- 9,51 201683 <br /> gnatur,a Date: CCB# (if applicable) <br /> Applicant is the ❑Owner EN Authorized Representative(form attached) <br /> G:BUILDING 1NSPECTIONTORMOSEPTICIS-01 ONSITE APPL JULY 2023 REV 6.23.DOCX Rev 1/15,3/13;6/22,6/23 <br />