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--X-3-ZL - 00 4 is Fs- ilAUTA-1- <br /> Application for Onsite Date Stamp: <br /> .- -- -" Wastewater Treatment System <br /> RECEIVED <br /> OM MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION JUN 2 5 2024 <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> .((,'\', \s—L) <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/Buildinglnsnection <br /> Property Owner Information <br /> AL R4`w.Sgr-CO titJ ,orfl �. Woo, <br /> •A Name Mailing Address qs es. <br /> Ge4, 64 5035570A)City,State,and Zip (Area Code)Phone <br /> ,8 Legal Property;Description <br /> cc.... azi‘c 042_ 4'406_ <br /> Property Address " City State Zip Code <br /> 093td7nB coAGO <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> C.Existing Facility I Proposed Facility./Water Information:, ', <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: ,�9 <br /> Public Gra- �j <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 /> a Type of Application. , <br /> ❑ Site Evaluation ❑ Renewal Permit VfflAuthorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement gr Replacing a Dwelling <br /> El Repair Permit El Permit Transfer The Addition of One or More Bedrooms <br /> ❑ Major El Minor ❑ Existing System Evaluation El Personal Hardship <br /> ❑ Alteration Permit El Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor El Other El Connecting town 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 ofEnvironmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> , n T?Oapi <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> 4 a 14 ;/9 v el rsek, ??3S� 614 Y6C."AO r f_pe,ti. cep <br /> Applicant's Mailin Address , Email: <br /> o AMACN 6�i 5�� y /6 2 R(51. <br /> Signature Date: CCB# (if applicable) <br /> HTTPS://MARIONCOUNTYGCC-MY.SHAREPOINT.COM/PERSONAL/BREICH_CO_MARION_ORUS/DOCUMENTS/DESKTOP/S-01 ONSITE APPL JULY <br /> 2024 REV 7.24-DOCX Rev 1/15,3/18,6/22,6/23 <br />