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,. .....�w_..w -,� ., _._ - _ <br /> III- 0-06(i Lic hiZ r <br /> Application for Onsite CE E P E <br /> D <br /> Wastewater Treatment System <br /> allMARION COUNTY PUBLIC WORKS MAY AY 28 2024 <br /> BUILDING INSPECTION DIVISION MARION COUNTY <br /> 5155 Silverton Rd.NE <br /> Salem OR 97305 BUILDING INSPECTION <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/Buildingnsnection <br /> Property.OwneHiiiiimati©n. . ,. . . . . <br /> L <br /> Namet ktes- P1A d( Prz pr,0'5 Mailing s Address � A W 1 b i t 4 a7,' i?i d <br /> t '4.kj / OIL Ti 22-S <br /> City State'and Zip (Area Code)Phone# <br /> B Legal Property Desc4,40: ' a f = <br /> 46 13A-1-es Poi S Se awt G t . l''"Ecie. <br /> Property Address City State Zip Code <br /> ()'S an 0OW SO ' I a.tV, <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> C ExishngFac hty/1!roposedFacility I Widerinformat1oq ' <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> L -r OPublic <br /> Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ �,_1 i.e( <br /> Seating Seating ® Private <br /> Well,Spring,Shared <br /> P e'of A tcation <br /> ❑ Site-Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Cnnstruction Permit 0 Permit Reinstatement ❑ Replacing a Dwelling <br /> Z.AZP06i got,. ❑ Permit Transfer 0 The Addition of One or More Bedrooms <br /> ''Major ❑ Minor 0 Existing System Evaluation 0 Personal Hardship <br /> [] A1reratiot4ermit 0 Record Review ❑ Temporary Housing <br /> ®:Major `0 Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> S - ,, lS *I-_ <br /> �, CIOther—Please Specify <br /> ?1 ",-3' <br /> If the requiredfee and attachrlttnts 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 /> 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 T ddres Email: <br /> c-/7- 201683 <br /> Si ture Date: CCB# (if applicable) <br /> pplicant is the 0 Owner IN Authorized Representative(form attached) <br /> G:\BUILDING INSPECITON\FORMSISEPTIC\S-01 ONSITE APPL JULY 2023 REV 6 23.DOCX Rev 1/15.3/18,6/22.6/23 <br />