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„, ,,,,,„ . Application for Onsite Date Stamp: <br /> --- - —1�;; Wastewater Treatment System 2 -� q 15Fsp mr- <br /> OMMARION COUNTY PUBLIC WORKS E c <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE '� <br /> Ll <br /> Salem OR 97305 MAY 2 9 2U24 <br /> (503)588-5147 Fax(503)588-7948 MARION COUNTY <br /> www.co.marion.onus/PWBuildinelnspection BUILDING INSPECTION <br /> A Property Owner Information <br /> Os A-'Val l 3'i pvi 4- 4-119-ey( 3'i/w S irt <br /> Name Mailing Address <br /> -i c41v is 0A 9?0 Z6 O3 fe S GY <br /> State,and <br /> -City, Zip (Area Code)Phone <br /> B.LegaI Property Description <br /> 7/3 ( wood 4nS&I r /v%sicd �cVa,7s citS <br /> Property Address City State Zi o e <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 /> ['Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ ID priv., <br /> Seating Seating <br /> Well, .pring,Shared <br /> D.Type of Application <br /> 0 Site Evaluation El Renewal Permit ❑Authorization Notice for: <br /> ❑ onstruction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> E RePennit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> PE Major El Minor El Existing System Evaluation ❑ Personal Hardship <br /> El Alteration Permit El Record Review El Temporary Housing <br /> ❑ Major El Minor El Other El Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> El 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 /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> er <br /> life/go 8 O 0 CD..S i /-cove <br /> Applicant's Mailing Address mail: <br /> ” '2 i—2-, / <br /> Si ature Date: CCB# (if applicable) <br /> Applicant is the Owner El Authorized Representative(form attached) <br /> G:\BUILDING INSPECTION\FORMS\SEPTIC\S-01 ONSITE APPL JULY 2023 REV 6.23.DOCX Rev 1/15,3/18,6/22,6/23 <br />