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21.f-CIO-1 I-7( PAM{ <br /> •,..,, Application for Onsite Date Stamp: <br /> -� _ Wastewater Treatment System D LE =v -E <br /> -� <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION SEA 0 2024 <br /> � <br /> y <br /> 5155 Silverton Rd NE <br /> Salem OR97305 NiARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 BUILDING INSPECTION <br /> wvvw.co.marion.or.us/PW/BuildingInsoection <br /> A.Property Owner Information <br /> � ejo Ic �ke-k(er tom aDX 2to2 <br /> Name Mailing Address <br /> SCO S M,LLS DR j7315 SO3 -- SS i —5b2 E <br /> City,State,and Zip 1 (Area Code)Phone# <br /> B.Legal Property Description <br /> 5 130 Bria h r � dlo I p Scot+s MILLS 0 ,e c 73 7S <br /> Property Address City State Zip Code <br /> 3`I.yy <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions^ � to Property: S c -r:--S AA I�s "�-d air-Do Le c �� �'ry 2d -I-0v1c IC, (Io,a 1' ct N E B r�'2r KGn0 b Loop J t <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> ,/ R.G. rca V� ❑Public <br /> rOvIle 3 Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ Private SFr'`nq <br /> Seating Seating <br /> Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> a 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 ❑ 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 /> ��ro 1d Ske+tev- 503 - 559 —vozg <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> F �,� 2b2 �c -t.s i rrs. OR 9 7 3 7 S " o2v1; l�e-�le� vcoy, <br /> Applicant's Mailing Address ail: <br /> f7 44'4t& Se f 1 20 241 <br /> Signa'"re Date: / CCB# (if applicable) <br /> Ap t icant is the 0 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 />