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i <br /> Application for Onsite Date Stamp: <br /> iiii-- ----:--_. 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/BuildingInspection <br /> A Property.;Ownei Information <br /> 1 <br /> Name Mailing AddreIs <br /> City,State,and Zip (Area Code)Phone# <br /> B ,Legal Property Description <br /> 7 6o e��r C Lei el..."' _q„ r ;i ote <br /> Property Address City State Zip Code <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> C Existing'Facrhty/:Proposed Facility/Water Information _ <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> DPublic <br /> Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ Private <br /> Seating Seating ❑ <br /> Well,Spring,Shared <br /> D Type of Application_ <br /> ❑ Site Evaluation ❑ Renewal Permit <br /> ❑Authorization Notice for: <br /> ❑ Construction Permit <br /> ❑ Permit Reinstatement <br /> ❑ Replacing a Dwelling <br /> air Permit ❑ Permit Transfer <br /> ❑ The Addition of One or More Bedrooms <br /> Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> 5-, <br /> ❑ Alteration Permit ❑ Record Review <br /> Ill Major ❑ Temporary Housing <br /> ❑ Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> /FI r ,/,__J 0 Olt, <br /> Please(over old) <br /> 6` ❑ Other—Ple 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 /> Depai tuient of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> Bethel Excavating 503-743-2343 36198 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> PO Box 504 Turner OR 97392 office@bethelexc.com <br /> Appi ant's Mailing Ad ess Email: <br /> 6011 44551 <br /> Signature <br /> Date: CCB# (if applicable) <br /> Applicant is the ❑ Owner ©Authorized Representative(form attached) <br /> G:\BUILDING INSPECTION\FORMS\SEPTIC\S-01 ONSITE APPL JULY 2023 REV 6.23.DOCX Rev 1/15,3/18,6/22,6/23 l <br /> e3 <br /> : <br />