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dq,6---631-5a <br /> ,, • Application for Onsite Date Stamp: <br /> %;-_. Wastewater Treatment System <br /> MARION COUNTY PUBLIC WORKS RECEIVED <br /> BUILDING INSPECTION DIVISION f����l !4 !>m® <br /> 5155 Silverton Rd NE qn <br /> Salem OR 97305 MAR 19 2024 <br /> (503)588-5147 .Fax(503).588-7948 <br /> www.co.marion.or.usiPW/BuildinInspection • <br /> A Property_Owner Information ! , <br /> --1\0 ZG -i`f .gfir\ Nt4 -(k\ \-\\ Cfvt <br /> Name Mailing Address • <br /> 17FG Ar Strike og 4-3 i25 SPA3 —43 a lit e <br /> City,State,and Zip (Area Code)Phone# <br /> ,B Legal Property Description .`_ _ti.._x:_ _ . F. S.". z r .r .° $Kitai_._ x..S.r..: Ek_`k .'N.",,._ ..> <br /> \171g S ' \W�AN\N\''')N c �1 <br /> Property Address City State Zip Code <br /> t°1 .c- ocre. <br /> Parcel# Tax Lot Acreage or Lot Size <br /> D'rections t q Pro erty: o ch c-a-tart R Q c6 a e 1— 6-.�"9 .�® a.eSOen ,,� .Di <br /> '�4�- :. qk.,t—. vet... . ,ei b .. 1t,-- 16.44 <br /> C E sting Facihty/Proposed Facility/Water Information 3 ' 1 <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> 0 r. kr-?dtr, ❑Public <br /> Atop Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ S umbeer of Employees/ �� <br /> Private <br /> D Type of Application <br /> Spring,GO Shared <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 /> El Alteration Permit •❑ Record Review ❑ Temporary Housing <br /> 0 Major 0 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 503-743-2343 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 /> OZ.A4 31/ 44551 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the ❑ Owner [Authorized Representative(form attached) <br /> G:\BUILDING INSPECTION\FOR vIS\SEPTIC\S-01 ONSITE APPL JULY 2023 REV 6.23.DOCX Rev 1/15,3/18,6/22,6/23 <br />