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ed,LA ZL95).5°) <br /> Application for Onsite Date Stamp: <br /> %e�. Wastewater Treatment System <br /> MARION COUNTY PUBLIC WORKS tl $ s <br /> BUILDING INSPECTION DIVISION <br /> AIM 1 w^,���., <br /> 5155 Silverton Rd NE L��� <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.ma rion.or.us/PW/Buildinelnspection <br /> ,A A Pit ert > o :0 _x.Z .x sENVOMME ... .,...M . ,. _a... a. „_ .max h. . ,E :.: _l <br /> Amber Johnson Hathaway 5173 SCenter St NE <br /> Name Mailing Address <br /> Salem, OR 97317 503-510-0058 <br /> City,State and Zip Ar <br /> ! -* ea Code)Phone# <br /> Flii'�, Dl g _ ' _.... } w ...... ........_. Ax..,... _fit..... mx,..t> i_.. s- x:''_^ ee €. -r.. .2_ `t n <br /> 5133 ),.. Salem OR 97317 <br /> Property Address City State Zip Code <br /> 072W29AB01500 /01400 / 01300 5.73 / 0.76 / 5.06 <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> Lc. i1r;r"d tirtP'r n:S + txi[ T�Dt�T rnftxriii*n E a .: .°_. ,_r >B, sW ,,3� ;s <br /> � „s <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> ❑Public <br /> 4 Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ 0 Private Well <br /> Seating Seating <br /> Well,Spring,Shared <br /> g T"ypPPIieagonV.PiWaizx....w> .Y_a.:E, .:; l_ .'- Vlis;. P4<;:...ry > _wAF.. . FS:, , _tP:VE2nN <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 /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ 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 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 /> Tyler Fuhriman 435-760-0717 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic. #(if applicable) <br /> 8727 SW 19th,Ave J Portland, OR 97219 tyler@fuhrimanconsulting.com <br /> Applicant's Mailing Address Email: <br /> 7/28/2024 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the ❑Owner 0 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 />