Laserfiche WebLink
aul- -(5b1D45 <br /> Application for Onsite DateS <br /> Wastewater Treatment System iECEt V MARION COUNTY PUBLIC WORKS AUG 12 2024 <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/P /Buildinelnspection <br /> A.Property Owner Informatioir <br /> k 1 uas '74/8-6/11-Aziti <br /> Name Mailing Address <br /> S 1/tlrs✓"7A. t _ <br /> City,State,and Zip (Area Code)Phone# <br /> B.Legal'Property Descr ption` <br /> 7Ll Wl+, i 1 St�vrr: tnvZ ac`7WQ1 <br /> Property Address City State Zip Code <br /> ,iw ./ D /ciO rah 1i ,IS— <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> C Exist ngFac ty/,Proposed Facility I Water Information, . <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ private klPl <br /> Seating Seating ! <br /> Well,Spring,Shared <br /> T afA lication <br /> yI?e PF <br /> ❑ Site Evaluation ❑ Renewal Permit C Authorization Notice for: <br /> ❑ Construction Permit 0 Permit Reinstatement ® Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer 0 The Addition of One or More Bedrooms <br /> ❑ 'Major ❑ Minor 0 Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit 0 Record Review 0 Temporary Housing <br /> ❑ Major' ❑ Minor 0 Other 0 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[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 Mailing Address Email: <br /> cr--/Z 201683 <br /> gnature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner if Authorized Representative(form attached) <br /> G:IBUILDING INSPECTION\FORMS\SEPTIC\S-01 ONSITE APPL JULY 2023 REV 6.23.DOCR Rev l/t5,3/18,6/22,6/23 <br />