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(91-1- be a'a.b <br /> Application for Onsite Date Stamp: <br /> Wastewater Treatment System <br /> MgMARION.COUNTY PUBLIC WORKS RECEIVED <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 JUL 1 1 2024 <br /> (503)588-5147 Fax(503)588-7948 <br /> 7 <br /> www.co.marion.or.us/PW/BuildingInsoection <br /> A.Property Owner Information .. <br /> ga.1 t tt- EJ 'a C 14COvk 1 S 10 ,GsSetwt&,- Ot t <br /> Name Mailing Address <br /> .544 ylet., O 12 al--13CrS SO3 r 53o i l <br /> City,State,and Lip (Area Code)Phone# <br /> A Lego-00 erfy,De§criptin, <br /> I s(0 C iSS4Lu✓e L.-t S 1t.y-- , o It Ot 7' .gi-3 <br /> Property Address City State Zip Code <br /> CC/ 1 I t 113.4 oo!Ya 666 it r <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: 14erz5L aI - e 1 erg- 663f401-'v t e <br /> 'C.Existing Fac lity/,Proposed Facility:I Water,Information. <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> L i — _ ciPublic , <br /> Named <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ 'rivate V1/eiI <br /> Seating Seating <br /> Well,Spring,Shared <br /> 'D Typeof Application'' . <br /> ❑ Site Evaluation 0 Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> Repair Permit 0 Permit Transfer ❑ The Addition of One.or More Bedrooms <br /> ® Major 0 Minor 0 Existing System Evaluation 0 Personal Hardship <br /> 0 Alteration Permit ❑ Record Review 0 Temporary Housing <br /> ❑ Major 0 Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 0 Other-Please Specify <br /> 1 tl stfS H-i �ytc191C �u (JSe St '^' c,,,- � 4—, 4.41 , ", t ' ; kzezSC <br /> If the required fee and attachments are not included with this application, it will be returned to oil 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 /> Oregon Sewer& Drain LLC 503-874-9414 38968 _ <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic. #(if applicable) <br /> PO Box 1282 Silverton. OR 97381 josh@oregonsewer.com <br /> Applicant's Tina res Email: <br /> ° '7-?-9...4-( 201683 <br /> - <br /> Si re Date: - CCB# (if applicable) <br /> pplicant is the ❑Owner [I Authorized Representative(form attached) <br /> G:IBUILDING INSPECTIONIFORMS\SEPTIC\S-0I ONSITE APPL JULY 2023 REV 6.23.DOCX Rev 1/15,3/18,6/22,6/23 <br /> . <br />