Laserfiche WebLink
, . <br /> , aL-1-6)-di 10 <br /> Application for Onsite <br /> Wastewater Treatment System RE 'E1 V E D <br /> l <br /> MARION COUNTY PUBLIC WORKS �9 2024PR A <br /> BUILDING INSPECTION DI•VISION <br /> 5155 Silverton Rd NE <br /> Salem OR.91305 <br /> (503)>588-5147 Fax,(503)588.7948 <br /> wwvv.co.marion:or.us/PW/Bulldinetnspection <br /> A:;Property Q" ier Tnformatioa„_ <br /> HTMmoo. •:Z ,..F.n <.:-: a I N7 ., a_-..� .D ;'YO <br /> Raul & Mary Campos 15217 Woodburn Monitor Rd NE <br /> Name Mailing Address <br /> Woodburn, OR 97071 503-989 City,State,an and Zip r r <br /> S� (Area Code)Phone# <br /> R J'Desciipt di <br /> 15217Woodbum Monitor Rd NE Woodburn OR 97071 <br /> r ._u._. <br /> Property Address City' State Zip Code <br /> 05.1 W25DC01500 0.30 <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> C'{t... g t ci V1 Pso ed=facility-Water:)lnformatio e " ,s_ <br /> Existing Residential. Proposed.Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> 4 DPublic <br /> Name <br /> Number of Bedrooms Number of Bedrooms Number of Employeesl Number of'Emplayees/ well <br /> Seating, Seatiag © Private <br /> Well,Spring,Shared <br /> D Type,o .4 ligation;; <br /> ❑ Site Evaluatione a�..._-., _•..;, ..�.,- �._ ..a t.,_.. ., ,,.,:., .� , . T,.� �:.�-: »._.., .�.�,x <br /> 0 Renewal Permit ❑Authorization Notice for. <br /> ❑ Construction.Permit ❑ Permit Reinstatement 0 Replacing:a Dwelling <br /> 0 Repair Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> 0 Major 0 Minor O. Existing System Evaluation <br /> 0 Personal Hardship Alteration Permit <br /> 0 Record Review 0 Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other <br /> El 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 rhay..e 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.Dent,e4t . <br /> is ( rk&nnc. 4)ppli p-ame Please Print Legibly Applicant s one Number <br /> DEQ Lic.*Of appilcable) <br /> Port,x56I, Moialla OR c703/5 <br /> Applicant's Mailing Address % � ` <br /> .—t—�f Email t %J"a1 <br /> Signature L.... � J <br /> Da CCB# (if applicable) <br /> Applicant is the 0 Owner KAuthorized Representative(form attached) <br /> Cr1BUILDING INSPECTIONIFORMS\SEPTIC\.-01 ONSITE APPLJULY 2023'REV 6.23.DOCX Rev I/15,3/18,622 6/23 <br />