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- 01-1-66ton(Q <br /> Application for Onsite Date Stamp: <br /> Z v Wastewater Treatment System <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> • (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/BuildingInsnection <br /> A.Property Owner Information <br /> i)o0gt .me, 'ears n 1 i-4'2- 4 ;6TA V vle- <br /> Name Mailing Address <br /> 6‘I eivt o Owc a'I-3o4— 5-03-9 30- 9.01 <br /> City, State, and Zip (Area Code)Phone# <br /> • <br /> B.Legal Property Description <br /> Q442- S 6SVAI NE Sa(cm ®L 6111 tic <br /> Property Address City State Zip Code <br /> e141 —ot . <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> ['PublicName <br /> --\-5---- <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ - <br /> Seating Seating <br /> Priv. <br /> gpSpring, Shared <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 /> Alt ation Permit la 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 /> ' 1\Ao � G-41 -."--q8—S8t.\ 3143 t <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> iq 43 14)a5ov. 440 c k-• SC Weµ ,DM °T3 VI- J'a.Wi\c4,A d L1/4tiS;-rur- o"tprot <br /> Applicant' ess Email: NiM <br /> g-4- 2o24- 234 VS- <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the ❑ Owner Authorized Representative(form attached) <br /> G:\BUILDING INSPECTION\FORMS\SEPTIC\S-01 ONSITE APPL JULY 2024 REV 7.24.DOCX Rev 1/15,3/18,6/22,6/23 <br />