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g4 -603 3-P, r <br /> Application for Onsite Date Stamp: <br /> Wastewater Treatment System RECEIVED <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION MAY 17 2024 <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 Owner"Information `' <br /> Name Mailing Address <br /> City,State,and Zip (Area Code)Phone# <br /> B Legal Property Description <br /> 6 2,00 Fett,4-I Ro iv Ater, nR 1 a 392_ <br /> Property Address City State Zip Code <br /> en UO2 E)Do tr • 2%2) 4 <br /> Parcel# Tax Lot Ecreage or Lot Size <br /> Directions to Property: t96y f�. ",� Q e etf .�,,, fir.. Q*ak 1_-,,cr t p (5'4�,p, <br /> 1/.7,4 k 4 r/n4s -- a o7 d P n MA 0,4 Lk 4 AN r F ?e.f +h <br /> C Existing Facilrty`I Proposed Facility/Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> ❑Public <br /> Name <br /> � <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ VI—Private <br /> Seating Seating � <br /> 63 Spring,Shared <br /> D_Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement El 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 /> El 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 /> � 1+e I in 44551 <br /> Signature Date: CCB# (if applicable) <br /> C:\USERS\ANAJERASANCHEZ\APPDATA\LOCAL\MICROSOFT\WINDOWS\INETCACHE\CONTEIT.OUTLOOK\3T7CT1Q3\5-01 ONSITE APPL JULY <br /> 2023 REV 6.23.DOCX Rev 1/15,3/18,6/22,6/23 <br />