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21-0033&o PIz -1 <br /> Application for Onsite Date Stamp: <br /> Wastewater Treatment System <br /> D ECEuv <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION .19 <br /> �J <br /> 5155 Silverton Rd NE APR 3 0 2024 <br /> Salem OR 97305 MARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 BUILDING INSPECTION <br /> A Property:OwnerInformahon <br /> -- gg1il am)Name QC.. rl�P.r �S�g4e,e Mailing Address <br /> Sc 4 •OR P-nes rd 7Z'/ i Jqz <br /> Crty,,State,and Zip _ (Area Code)Phone# <br /> B Legal Property Description <br /> c x <br /> rs 05 e14 co, ®/ by rF -rtd.ro,er oR g7 1Z <br /> Property Address City State Zip Code <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Pro e <br /> P <br /> :ten etrinS' <br /> inn 9CA - CI( 4,14 ri.. <br /> C Ezishng Facility/Pro osed Facility/Water.Informahon <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> �I ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ Private <br /> Seating Seating <br /> ell,Spring,Shared <br /> D Type of Apphcation <br /> ❑ 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 /> ReAeif 61 /2.cI J.174 44551 <br /> Signature Date: CCB# (if applicable) <br /> C:\USERS\ANAJERASANCHEZ\APPDATA\LOCAL\MICROSOFT\WINDOWS\INETCACHE\CONTENT_OUTLOOK\3T7CT1Q3\S-01 ONSITE APPL JULY <br /> 2023 REV 6.23.DOCX Rev 1/15,3/18,6/22,6/23 <br />