Laserfiche WebLink
Application for Onsite Date Stamp: <br /> Wastewater Treatment System ���/��I EU�-L- <br /> qz_tMARION COUNTY PUBLIC WORKS RECEIVED <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE JUN 17 2024 <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> svww.co.m arion.or.tts/P%'%/Buildingl nspection <br /> A.Property Owner Information <br /> Keith and Zoe Kersey 17122 Fern Ridae RD SE <br /> Name Mailing Address <br /> Stayton, OR 97383 503-769-7586 <br /> City,State,and Zip (Area Code) Phone# <br /> B.Legal Property Description <br /> 23527 Santiam Way SE Lyons OR 97358 <br /> Property Address City State Zip Code <br /> 4 092E17AB01200 . 62 <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: heading east on HWY 22 out of Stayton for 10 miles, turn left <br /> on Santiam Way SE . <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> ❑Public <br /> 4 Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number or Employees/ <br /> Seating Seating ® Private Shared <br /> Well,Spring, Shared <br /> D.Type of Application <br /> ❑X Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> El Construction Permit El Permit Reinstatement El Replacing a Dwelling <br /> El Repair Permit ❑ Permit Transfer Cl The Addition of One or More Bedrooms <br /> ❑ Major El Minor El Existing System Evaluation 0 Personal Hardship <br /> El Alteration Permit ❑ Record Review El Temporary Housing <br /> ❑ Major El Minor El Other El 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 he 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 /> Vernon Lacey 503-999-4810 <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> 23537 Santiam Way SE Lyons, OR 97358 yeca130@yahoo . com <br /> Applied is Mailing Address // Email: <br /> Signature Date: CCB# (if applicable) <br /> HTTPS:f/MARTONCOUNTYGCC-MY.SHAREPQENT.COM/PERSONAL/BREJCH CO MARION O_ R_US/DOCUMENTS/DESKTOP/S-0i ONSITE APPL JULY <br /> 2024 REV 7.24.DOCX Rev 1/15,3/18,6/22,6/23 <br />