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Application for Onsite a 3+bb3g� <br /> -— r1' Wastewater Treatment System <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION OCT 04 2023 i <br /> 5155 Silverton Rd NE — <br /> Salem OR97305 MARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 BUILDING INSPECTION <br /> www.co.marion.or.us/PWBuildingInspection <br /> A.Property Owner Information <br /> Thomas E. Barnett 12814 Arndt Rd NE <br /> Name Mailing Address <br /> Aurora, Oregon 97002 (503)866-9024 <br /> City,State,and Zip_.. . . (Area Code)Phone# <br /> B.Legal Property Description <br /> 128Z4 Arndt Rd NE Aurora OR 97002 <br /> Property Address City State Zip Code <br /> T4S;R1W; Section 3 700 35.50 Acres <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: 35.5 acre lot that we are putting a manufactured home on for employees. <br /> C.Existing Facility I Proposed Facility/Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> 4 ['Public <br /> 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 /> D•Type of Application <br /> ® Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑x C• onstruction 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 /> ❑ A• lteration 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 /> Thomas E. Barnett 503-866-9024 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> 12814 Arnd Rd NE Aurora, Oregon 97002 thomasebarnett@yahoo.com <br /> Applis Mailing Address Email: <br /> �. 9/28/2023 <br /> igi Lure Date: CCB# (if applicable) <br /> Applicant is the ®Owner ❑Authorized Representative(form attached) <br /> G:IBUILDING INSPECTION\FORMS\SEPTIC\S-01 ONSITE APPL JULY 2023 REV 623.DOCX Rev 1/15,3/18,6/22,6/23 <br />