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04-elt)(12g34& <br /> Application for Onsite Date Stamp: <br /> Wastewater Treatment System <br /> MARION COUNTY PUBLIC WORKS <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.orms/PW/Buildindnspection <br /> v <br /> Kryn & Irene van Loon (van Loon Farm, LLC) 13121 Jefferson Hwy 99E SE <br /> Name Mailing Address <br /> Jefferson, OR 97352 541-974-4699 <br /> Ctty,State,and Zip (Area Code)Phone# <br /> 13471 Jefferson Hwy 99E SE Jefferson OR 97352 <br /> Property Address City State Zip Code <br /> 600 O93W260000600 125.76 <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Pro a From Salem, go south on 1-5,take Jefferson Exit#244,turn left, go 2.6 miles,turn right on to 13471 <br /> Pry: <br /> C x st�nr cal / ragpsed, c i ty f WAter nformatoel;.,zt 3 . F. <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> 5 ['Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ I� Private Well <br /> Seating Seating <br /> Well,Spring,Shared <br /> "type©f'APPllcat�o <br /> va ua ton ❑ Renewal Permit ['Authorization Notice for: <br /> [ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> El Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> El Major El 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 /> Irene van Loon 541-974-4699 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic. #(if applicable) <br /> 13121 Jefferson Hwy 99E SE, Jefferson, OR 97352 krynirene@hotmail.com <br /> Applicant's Mailing Address Email: <br /> 05-06-2024 <br /> Signature Date: CCB# (if applicable) <br /> C:\USERS\ANAJERASANCHEZ\APPDATA\LOCAL\MICROSOFT\WINDOWS\INETCACHE\CONTENT.OUTLOOK\FKJL2DXT\S-O 1 ONSITE APPL JULY <br /> 2023 REV 6.23.DOCX Rev 1/15,3/18,6/22,6/23 <br />