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egg—or,t251- PRn <br /> Application for Onsite Date Stamp: <br /> ;.:..,_ <br /> ---=-%� Wastewater Treatment System <br /> '1111111' MARION COUNTY PUBLIC WORKS RECEIVED <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE J U N 03 2024 <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/BuildingInspection <br /> A Property Owner Information_......_ <br /> Ay,n 4 14 vti 1 ZOO CIAW1.41 54. NC <br /> Name Mailing Address <br /> vl:•L cit OR C1707-a q71 - 7_21 - 3 '3o <br /> City, State,and Zip (Area Code)Phone# <br /> B'..LegalProperty Description <br /> 11 S P14plc_ s1. 641Cs q - j<,'(.9 <br /> Property Address City State Zip Code <br /> �cl EZGC_t300700 o 74/ <br /> Parcel# Tax Lot �) Acreage or Lot Size <br /> Directions to Property: ffkS)- b vi 1"' y Z Z 'l�o G..4e-5 ) !1 rol. Nov- p vi <br /> P Y Ckl.p L •1-. I t 6 o� e C1.l-I.1! r`� 4-0M<p k S I. 'tea Vs R. t, i e•, <br /> C.Existing Facility/Proposed Facility!Water Information. <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> 16Public G 4cs <br /> Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ <br /> Seating Seating ❑ Private <br /> Well,Spring, Shared <br /> D_Type of Application <br /> ❑ Site Evaluation ' ❑ Renewal Permit ❑Authorization Notice for: <br /> • Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> �i1 Repair Permit ❑ Permit Transfer El The Addition of One or More Bedrooms <br /> ❑ Major ill 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 /> Keh I60ze. E'Xe4%) trN 5b3 -g32- oqy 39231 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> 8 G Z Y G Ltk L.,, c_4. 5 t 5<low,, a& 47.31'7 w T eXc,c 0..4,:mg ao 1. Cow. <br /> Applicant's Mailing Address Email: <br /> L 2 1 -Z v t G S- $ cis <br /> Signature D te: CCB# (if applicable) <br /> Applicant is the ❑ Owner 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 />