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(914 -tx)61 <br /> Application for Onsite Date Stamp ® E E <br /> Wastewater Treatment System <br /> MARION COUNTY PUBLIC WORKS JUL 2 2024 <br /> BUILDING INSPECTION DIVISION MARION COUNTY <br /> 5155 Silverton Rd NE BUILDING INSPECTION <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/BuildingInspection <br /> P� keV 23S8 f r . SE <br /> Name Mailing Address <br /> 1.e. ov•. 012, q �5z-- S63 31(.1' We) <br /> City,State,and Zip (Area Code)Phone# <br /> B.ILe pl PYo a 0CS 1: tlOri <br /> I ZZ33 Se cloc1 ccN. 'Pt St- g-e.(2 -to-50‘,. f�\Z 01'13 <br /> Property Address City State Zip Code <br /> C.X13 7 Z3 A CC)1 y c'/ I `{O .ef <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: TWA Ct}' Asa-* e.vd ( , <br /> C Ex�stmg Facility/Pro a /Watertnforuiatio, a I <br /> Existing Residential: roposed Residenti. t Existing Commercial: Proposed Commercial: Water Supply: <br /> ['Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ Vrivate • <br /> Seating Seating <br /> Well,Spring,Shared <br /> D pie o Appl►eahon qe �... _7A� <br /> ite Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> V Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ 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 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 /> Ca-c-k- '4t)3 3c-kG1 �lC Qj <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> cliq ki;111"`e, wa_y &J(A) C.aC1�52 01.41 .co„.— <br /> Applicant's Mailing Ad ss Email: <br /> 7/V4(2y <br /> Signature Date: CCB# (if applicable) <br /> HTTPS: ONCOUNTYGCC-MY.SHAREPOINT.COM/PERSONAL/BREICH_CO_MARION_OR_US/DOCUMENTS/DESKTOP/S-0I ONSITE APPL <br /> AUGUST 2024 REV 8.24.DOCX Rev 1/15,3/18,6/22,6/23 <br />