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Vl-0057H, <br /> Application for Onsite Date Stamp: <br /> --- Wastewater Treatment System <br /> MARION COUNTY PUBLIC WORKS NECE - <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE J U L 0 2 2024 <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 MARION COUNTY <br /> www.co.marion.or.us/PWBuildinglnspection BUILDING INSPECTION <br /> A.Property Owner Information <br /> ()\ \Nf\O\ 'Ms o pry 7N.i%t <br /> Name Mailing Address <br /> a.\ 9.-akWom`J <br /> City,State,and Zip (Area Code)Phone# • <br /> B.Legal Property Description <br /> 2J3 is Ip \ ' U►``e.e.\ �1\ `1A ��31 <br /> Property Address City State Zip Code <br /> DnE 0113 roc <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ fg Private el\ <br /> Seating Seating <br /> Well,Spring,Shared <br /> D.Type_of Application - <br /> 14 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 /> ❑ 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 /> Bethel Excavating 5037432343 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 /> Applicant's Mailing Address Email: <br /> 84_ 06461 = , 2-0 Zy 44551 <br /> Signature Date: CCB# (if applicable) <br /> C:\USERS\ANAJERASANCHEZ\APPDATA\LOCAL\MICROSOFT\WINDOWS\INETCACHE\CONTENT.OUTLOOK\3T7CT1 Q3\S-01 ONSITE APPL JULY <br /> 2023 REV 6.23.DOCX Rev 1/15,3/18,6/22,6/23 <br />