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Application for Onsite Date Stamp: <br /> ----%;, Wastewater Treatment System <br /> MARION COUNTY PUBLIC WORKS <br /> RE C ETV E <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE AUG 0 6 2024 <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 MARION C <br /> OUNTY <br /> www.co.marion.or.us/PWB tuildingInspection ulLDINO INSPECTION <br /> _A Property Owner Information <br /> JeD jG' ShQ,t\ ,r 2 03'1 O ha,ill ap /d <br /> Name Mailing Address <br /> . bk d ills Cr. C1-31- 5-0,- 5 --$c=.2g • <br /> City,State,and Zip' (Area Code)Phone# <br /> B.Legal PropertyDesciiption . <br /> 1 0 15ha.r \e,n,D h Lp Sc,bMH(I I b 6Z. C11-- <br /> Property Address City State Zip Code . . <br /> 31 . Lill <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> C..Existing Facility I Proposed Facility/'Waterruformation: <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> n ['Public <br /> a <br /> �Q Name <br /> Number of Bedrooms Number of Bedrooms Number beer of mployees/ Number of Employees/ private TO in Well,Spring, �ared <br /> D.Type of Application...... <br /> 6 Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement El Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation El Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> El 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 /> Jero1.d cShek `e,r 503 --55 q - $ 2-g <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> 0 0110 '(Y1cUtOr Fa S(i) f111is ()l2 a 1-5 sa an+ahich wnitSM91411-0(14 <br /> Applicant's Mailing Ad ess L Email: <br /> a e GAT 6 1. Z( C)0-74Ye-71, <br /> ture D t . CB# (if applicable) <br /> cant is the Owner ❑Authorized Representative(form attached) <br /> G:\BUILDING INSPECTIO ORMS\SEPTIC\S-01 ONSITE APPL JULY 2023 REV 6.23.DOCX Rev 1/15,3/18,6/22,6/23 <br />