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2`j-o_oe-f(Zci EviarL- <br /> Application for Onsite Date Stamp: <br /> Wastewater Treatment System <br /> MARION COUNTY PUBLIC WORKS lAy 15 2074 <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE MARION COUNTY <br /> Salem OR 97305 �'(-'(Lf,(,�I� fi\NSP <br /> (503)588-5147 Fax(503)588-7948 �T(l� <br /> www.co.marion.or.us/PW/BuildineInsuection <br /> 77.7 <br /> _A.Property.Ownerinformatzanr,`'' • , .._..._ 177-_..7._. <br /> Lou Ellen Pearson 496 Tierra Ct. <br /> Name • Mailing Address <br /> Salem,OR 97301 503-559-3218 <br /> City,State,and Zip (Area Code)Phone# <br /> LEtegal-Property llescriptiou _ �. • ,.. � .. ._ _ ' . �ro...�'`. . _ „._..a,.,b�ur <br /> 1808 Farmer Rd SE Jefferson OR 97352 <br /> Property Address City State Zip Code <br /> 093W23B 000800- Parcel#2 3.37 Acres <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: S.on Jefferson Hwy 99E from 1-5, 1-1/4 Miles, Property is on left <br /> ,C.Existing Facih f ProP ll F"a'ethtv=l Water Tnformation . .°" N z <br /> Existing Residential: proposed Residential. Existing Commercial: F^s Proposed Commercial: Water Supply: <br /> ['Public <br /> •(f Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ ® private Well <br /> Searing Seating <br /> Well,Spring,Shared <br /> D.;T_ e of Applccatton; <br /> 0 Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer El The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> El 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 famished 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 /> Micah Hozen dba New Creation Contracting 503-710-2565 38988 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic. #(if applicable) <br /> 31366 Oak Plain Dr. micah@newcreationco.net <br /> Applicant's Mailing Ad ss Email: <br /> ------ 2/20/2024 201065 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the ❑Owner ❑X Authorized Representative(form attached) <br /> G:\BUILDING INSPECTION\FORMS\SEPTIC\S-01 ONSITE APPL JULY 2023 REV 6.23.DOCX Rev 1/15,3/18,6/22,6/23 <br />