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<br /> Application for Onsite Date Stamp:
<br /> Wastewater Treatment System (92.-/_,z706 690 piejerrr
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<br /> .- MARION COUNTY PUBLIC WORKS RECEIVED
<br /> BUILDING INSPECTION DIVISION -..
<br /> 5155 Silverton Rd NE
<br /> 4' Salem OR 97305 JAN 2 4 2024
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<br /> (503)588-5147 Fax(503)588-7948
<br /> www.co.marion.or.us/PW7BnildingInspection
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<br /> $ A Property Owner Information
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<br /> Name Mailing Address r-:::' V - -- i.,•'1:-'7,' .
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<br /> KPacco\-\\he, —c-0' C1-4913 (cc--4 1774X-015 7.70
<br /> City,State,and Zip (Area Code)Phone#,
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<br /> .... . „ ,,,,B.Legal Property DescriptiOn. .'_, . ,, •. ,.
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<br /> Property Address , City •State Zip Code ,
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<br /> Parcel# Tax Lot . 41 Acreage or Lot Size
<br />- : -*.-. •. .Directions to Property: ffOrsi 'Pone,( - Vol-in, -19-w4A-:.-z.-6,v-t ?eNteiin terc CA.rx .-1-itc•Hr C'4-1.:••\\!,Ne. \ ,-
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<br /> C.pasting Facility/Proposed Facility/Water Information ' _ :"-- ','„. ' ; ,
<br /> Existing Residential: Proposed Res' ' . Existing Commertial: Proposed Commercial: Water Supply
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<br /> „ s Name a 1 • .,.
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<br /> Number of Employees! Number of Employees! lPrivte, WO i Numb r o Bedrooms • Number of Bedrooms ' -
<br /> Seating Seating
<br /> Well,Spring,Shared
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<br /> D.Type of Application -f!::-; '
<br /> 4 • I:: Site Evaluation -',-;',L. 1=1 Renewal Permit DAuthorization Notice for: .,.$'-•?-
<br /> -• []..Construction j'",`-', 0 Permit Reinstatement i 0 Replacing a Dwelling
<br /> ._ Re 9 air Permit ' -_--r- El Permit Transfer 0 Tly Addition of One or More Bedrooms
<br /> Major I=I Minor - El Existing System Evaluation 1=1,14eksonal Hardship .--
<br /> 1=1 Alteration Permit•- El Record Review
<br /> a-temporary Housing
<br /> El Major D-.Minor El Other -. 4P, El Connecting*an Existing System Never in Use-,. (over 5-yt5, d)
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<br /> 4, E Other—Mtge Specify .. •,A=c,---4—,
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<br /> If the required fee and attachments'ake not.included with this application, it will be returned to you as incolete. .
<br /> Post the orange'card at the entranceto the Property. Flag the test holes.• , „ f'
<br /> By my signature,I certify that the information I have furnished is correct aria=haeby grant Marion County,authorized agent of the
<br /> • Department of Environmental Quality,kiiniion to enter onto the above described property for the sole purpose of this application.
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<br /> Applicant'siName L,Plese Print Legibly' i Applicant's Phone Number DEQ Lic. #(if applicable)
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<br /> Applicant's Mailing Address Eitail: ,..)
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<br /> - - - , C.4.Date: ;4. ;- CCB# (if applicable)
<br />„ • Applicant is the 1=I Owner ,...E .Ici.thorized Representative(form attached)
<br /> GABUILDING INSPECTIONNFORMS\SEPTIC\S-01 ONSITE APPL JULY 2023 REV 6.23.DOCX Rev 1/15,3/18,6/22,6/23
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