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a•IA-t5btAL-V6 <br /> Application for Onsite Date Stamp: <br /> Wastewater Treatment System ECE VED <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION AUG 15 2024 <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> vvww.co.marion.or.us/PW/BuildineInspection <br /> A.Property Owner Information ' L\ aa-da 1 <br /> Tar i5 M J3ur405a Li v M3 Yiu4 1 t lv7a Z5k'n4 Dr-,SE <br /> Name Mailing Address <br /> 3faTinn, oe g73- 6/) -4'030 and <br /> City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> /043 /1 Sizty,br) did SE Pa m5vi 11 z dQ 97.3a <br /> Property Address City State Zip Code <br /> h9el) prrs pf.1 .�5 nacres <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> a _ ['Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ �Private will <br /> Seating Seating <br /> Well, Spring; Shared <br /> • <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 ❑ Minor Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit M, Existing <br /> Review ❑ Temporary Housing <br /> ❑ Major El 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 /> S 449—M020 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> 41W70 J75/and 7r S S-ky-�r), De g0 ea7' niar Czu r n�cam <br /> Applicant's Mailing Address Email: <br /> ig- <br /> Signature Date: CCB (if applicable) <br /> Applicant is the ❑ Owner Ri.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 />