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Application for Onsite Date Stamp: <br /> 10. <br /> Wastewater Treatment System RECEVED <br /> mi.- ---.2..::---, <br /> MARION COUNTY PUBLIC WORKS OCT 16 2023 <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 MARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 BUILDING INSPECTION <br /> www.co.marion.or.us/PW/BuildingInsnection <br /> A Property Owner Information'" <br /> Justin Cherrington 1206 LOTTIE LN NW <br /> Name Mailing Address <br /> SALEM, OR 97304 <br /> City,State,and Zip (Area Code)Phone# <br /> B.Legal 2,ro.•rty Description <br /> 107 E 3t'- ' , = .: web Gates OR 97346 <br /> Property Address City State Zip Code <br /> 093E26CCO2800 .15 <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: Access property from Horeb St <br /> C.Existing Facility/Proposed Facility/Water Information . <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> ❑p Public Gates city water <br /> 2 Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Numeatingber of Employees/ 0 Private <br /> Seating <br /> Well,Spring,Shared <br /> D.Type'of Application <br /> 0 Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit 0 Permit Reinstatement ❑ Replacing a Dwelling <br /> g Repair Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> 0 Major '54 Minor ❑ Existing System Evaluation 0 Personal Hardship <br /> 0 Alteration Permit 0 Record Review 0 Temporary Housing <br /> ❑ Major ❑ Minor 0 Other 0 Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 0 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 /> Flow Line Construction 503-871-2260 39474 <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> 11805 State St Salem Or, 97317 construction.flowline@gmail.com <br /> Applicant' ilAddress Email: <br /> � / 7 10/11/23 239492 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner ®Authorized Representative(form attached) <br /> G:\BUILDING INSPECTION\FORMS\SEPTIC\.-01 ONSITE APPL JULY 2023 REV 6.23.DOCX Rev 1/15,3/18,6/22,6/23 • <br />