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• a1-1-nce53 <br /> Application for-Onsite RECEIVED <br /> Wastewater Treatment System <br /> MARION COUNTY PUBLIC WORKS AUG 16 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/PWBuildinelnsnection <br /> Amber Johnson Hathaway 5173 SCenter St NE <br /> Name Mailing Address <br /> Salem, OR 97317 503-510-0058 <br /> City State,and Zip m m m (Area C9491 Phone# <br /> rn <br /> 11;1L;I 4" I:Fiope 1 esara <br /> . 5133 Of l - __ 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 /> F C Exist__ngj acilily/'Proposed Eacilety I Water lnformaihouw M zgf _.. 7 t ;aktRA::KC P, <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> ['Public <br /> 2 Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ lII Private Well <br /> Seating Seating <br /> Well,Spring,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 p Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review El 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 I Portland, OR 97219 tyler@fuhrimanconsulting.com <br /> Applicant's Mailing Address Email: <br /> 8/12/2024 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the ❑Owner ❑■ 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 />