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! oVi-61)U-k 64 <br /> Application for Onsite Date Stamp: <br /> " , Wastewater Treatment System <br /> MMARION COUNTY PUBLIC WORKS RECEIVED <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE AUG 14 2024 <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> wwvv.co.marion.or.us/PW/BuildingInsuection <br /> A Property_Owner information } <br /> 6NL>JMN7L, &?n wAys LL.( fo ilv,k /10 / <br /> Name Mailing Address <br /> LVit$1 io ' / S73S- • SSI/' -21-q.S6 0 <br /> City,State,and Zip - ;.. (Area Code)Phone# _ <br /> ': , <br /> B.Legal Property Description. <br /> 132 !ivy v,c w Si CrA ItS UY 5' ??ki6 <br /> Property Address City State Zip Code . <br /> 09 3 E 210 e_- C- 04,360 2 • 0 0 <br /> Parcel#ar 1 Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information t. <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Soppy: <br /> • <br /> Public (43 7i� 5 <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ ❑ private <br /> Seating Seating <br /> Well,Spring, Shared <br /> D T: e of Application <br /> NI Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ❑ 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 /> \J✓ lw1 A - tuAl0 ,cek ` 17O/ - 3S ) <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> PO /;b )c 116 1 l:C6AA1 o Iv O& / q -3 S'5 VJt�aivoy.. A►LF3A fly€YI t/aD <br /> Ap licant'sMain dress Email: leo �, <br /> $' oz- zci <br /> Signature ate: CCB# (if applicable) <br /> Applicant i e ❑ 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 /> - <br />