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, <br /> oPii,000- b <br /> Application for Onsite Date Stamp: <br /> _---1���fv Wastewater Treatment System RECEIVED <br /> allMARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION APR 17 2024 <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 . <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/BuildingInsnection <br /> 'A Pro Owner Information . <br /> A h/h oh f e© ws'oII 1I g' jv` Sa—nF%et-n iledy <br /> Name L Mailing Address <br /> C-6-1�5 6rpCA914 ,503-- 38'3— 8a33 <br /> City, State,and Zip (Area Code)Phone# <br /> B_ itsiI Property`Desetip on._. —._ :_ -- 7 ' .______.•__.—___ <br /> If F i\J, 5 CrY14-;a.in wl1 Cr,G-/ c)1Z 9 73 /C <br /> Property Address City State Zip Code <br /> iloGk- rn L-„f- I o cr,3 .Ea7 04 o i ac° 1.03 x aas— <br /> Parcel# Tax Lot Acreage or Lot Size _ <br /> Directions to Property: S, f a ��rt� l'o G o 5 Sec_a Rd ( 0 1` P- I- (;-o e'►l e 6 <br /> 0Ace LO- <br /> C Eaxstmg Facjlity/Praptised Facility/Water Iaformation - <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: [ ! <br /> rx 049 ❑Public -&`fy C-7 uS <br /> Name <br /> Number of Bedrooms Number of Bedrooms Number ofEmployees/ Number ofEmployees/ ❑ Private <br /> Seating Seating <br /> Well,Spring,Shared <br /> D Typeof Apphcatioa. 1 <br /> Site Evaluation ❑ Renewal Permit Authorization Notice for: <br /> ❑,Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> L ep it Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Iteration Permit ❑ Record Review;7 ❑ Temporary Housing <br /> El Major ❑ Minor ❑ Other /"e.rW,/I- El 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 /> vfr 1 IV -o&o't CO3;733-- aas) 39/do <br /> Applicants Name—Please Print Legibly Applicants hone Number DEQ Lic.#(if applicable) <br /> .5R3a JvhIptr 5$i- jv-e- Sa-1e,,,, g7j(?c- CL5�,2 6) )6,2-A00 , cool <br /> Applicant's Mailing Address Email: <br /> A, Pad gi q <br /> Signature I Date: CCB# (if applicable) <br /> Applicant is the ❑Owner RAuthorized 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 />