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) .Jg3L <br /> Application for Onsite - nape stamp: <br /> nlWp1 <br /> —_imi Wastewater Treatment System 4 <br /> MARION COUNTY PUBLIC WORKS PECEB M E I <br /> BUILDING INSPECTION DIVISION 5155 Silverton Rd NE JUN 24 2024 <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.ma rion.or.us/PWIBuildinglnsnection <br /> A.Property Omer Information;... <br /> Er•Ltwt a t i lit k. & 4, g51 5, ..r.r,./ 1'x2 Na <br /> Name Mailing Address <br /> S e few( C>C ci7 305— <br /> City,State,and Zip (Area Code)Phone# <br /> Le 'C_ro e, Description <br /> .._..-._�,�' -per' . �_.._ <br /> g—i Suvu1 y UteA) ra Aid' Se-ie c lz 41 3 <br /> Property Address City State Zip Code <br /> 077,.W w /6/40 G4l00 6,qd) <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> C Existing Fac tti4Proposed;I xczhty/;Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> CA ,, ['Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees Number of Employees! Private W,L/ <br /> Seating Seating <br /> Well,Spring,Shared <br /> uD 'Type of Applcatron <br /> ❑ Site Evaluation 0 Renewal Permit VAuthorization Notice for: <br /> ❑ Construction Permit 0 Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> Major ❑ Minor 0 Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit 0 Record Review 0 Temporary Housing <br /> ❑ Major ❑ Minor 0 Other 0 Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 14 m. fe, gj 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 /> 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's Mailing Address Email: <br /> 4 ..(' Q--( 201683 <br /> Si a Date: CCB# (if applicable) <br /> plicant is the ❑Owner gcl Authorized Representative(form attached) <br /> G:\BUILDING INSPECTIONTORMS\SEPTIC\S-01 ONSITE APPL JULY 2023 REV 6.23.DOCX Rev 1/15.3/18,6/22,6/23 <br />