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6i-0-03(e7it Piam <br /> Application for Onsite Date Stamp: <br /> Wastewater Treatment System Q f <br /> CEVE/9 <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION A 1 c 2�2 <br /> Bli <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 MAR!Of'j COUNTY <br /> UILDINw� G iNSP <br /> (503)588-5147 Fax(503)588-7948 E�TiQN <br /> www.co.marion.or.us/PW/BuildingInsnection <br /> A rQ ert O nmat�o <br /> Joseph Mitchell 817 Meadows Ln SE <br /> Name Mailing Address <br /> Jefferson,OR 97352 971-218-1243 <br /> City,Stater and Zip _ a (Area Code)Phone# <br /> 817 Meadows Ln SE Jefferson OR 97352 <br /> Property Address City - State Zip <br /> ty Code <br /> 093W15B 000601 1.98 Acres <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property:I-5 S to Exit 244, Rt on 99E,Lt on Meadows Ln SE,0.6 miles,property is on rt <br /> C.Existing £ t`• ,.Proposed,tacllity l Water i a tt =.7; ._... ':• ._.._..� <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> ['Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ privateShared Well <br /> Seating Seating <br /> Well,Spring,Shared <br /> • <br /> D°,Ty e of A lieatian ::::' . ._.a.. Pu7 T.: Zg, ev..�.N,. _r. ::;: 57F 4 _r <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> x❑ 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 /> Micah Hozen dba New Creation Contracting 503-710-2565 38988 _ <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic. #(if applicable) <br /> 31366 Oak Plain Dr. micah@newcreationco.net <br /> Applicant's Mailing Ad ss Email: <br /> • 201065 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the ❑Owner ❑x 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 />