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mumbri <br /> • <br /> Application for Onsite � <br /> We REr e C to � <br /> Wastewater Treatment System <br /> M ARION COUNTY PUBLIC WORKS AUG 15 2024 <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PWBuildin2Inspection <br /> ' - <br /> D3D <br /> A.Property Owner Information: � <br /> D ri s M Bar 5Z Li a Tru31-- 41&1D eland Dr LE <br /> Name Mailing Address <br /> s 44019, C� g73g-3 3-I3,P e ►r>Lcr . <br /> City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> /Do "Fd_Sr Alims v i 1lt 6L. 97 � <br /> Property Address City State Zip Code <br /> 1OOO ra f�, 2,`gib acres <br /> Parcel# Tax Lot 'A reage or Lot Size <br /> Directions to Property: <br /> - <br /> C.Existing Facility. /Proposed Facility/Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ Private tUo1 <br /> Seating Seating <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 /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major El 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 /> L0-1- Line aA uS-bmccrf <br /> If the required fee and attachments are not included with this application, it will be returned to you as ineomplete. <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 /> Depai liuent of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> Mark_S Sharnaei 69.3-9Ao*o > <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> 4670 .�.-74'nd VKS& 57 fin q7 r3- ,Co/1 <br /> Applicant's Mailing Address Email: <br /> Signature Date: 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 />