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Application for Onsite Date Stamp: <br /> ; ., Wastewater Treatment System <br /> MARION COUNTY PUBLIC WORKS RECEIVED <br /> BUILDING INSPECTION DIVISION 5155 Silverton Rd NE SEP 0 52024 <br /> Salem OR 97305 • <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/BuildingInspection <br /> dames — QA 67 4o)en / )1 of SG- <br /> Name Mailing Address <br /> 3 e' i soo C R 97 3c2- 77. -- 30 3 —6 2) <br /> City, State,and Zip (Area Code)Phone# <br /> 67 4n HA �d sE 3 T?ce 17352-- <br /> Property Address City State Zip Code <br /> Pefeel# TskZot " use e Lo.'-e', <br /> re <br /> ctions to Pro e <br /> C EX15t1WF'd4l...1i ttiO sed' Cl*V ate ' iji14i Qll`Fg ". <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> ['Public <br /> Name <br /> Number of Bedrooms Number of Bedroo s Number of Employees/ Numberg of Employees/ . e <br /> S Seatin <br /> Well, pring,Shared <br /> k.D [• ofA 11Ca�1t111 �.:x ..,_ _...w;__ � � � � �s�� ssz°<'��3"�t � :e � z s � a .,.777 <br /> .. <br /> ❑ Site Evaluation ❑ Renewal Permit uthorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑:Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer /�7�1 The Addition of One or More Bedrooms <br /> ❑ Major ❑ 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 /> 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 /> �a�S 906to 77C 3©3 2(3 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> 67 'AI)6 14111 N 7\ sftym't3P3moi L (b <br /> Applicant's Malin dress `J <br /> igna e Date: CCB#(if applicable) <br /> A li ant is the Owner ❑Authorized Representative(form attached) <br /> G:\BUILDING INSPECTION\FORMS\SEPTIC\S-01 ONSITE APPL AUGUST 2024 REV 8.24.DOCX Rev 1/15,3/18,6/22,6/23,8/24 <br />