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a3'ttRle69-e\faQ <br /> Application for Onsite Date Stamp: <br /> Wastewater Treatment System <br /> rMARION COUNTY PUBLIC WORKS l <br /> BUILDING INSPECTION DIVISION t� U <br /> 5155 Silverton Rd NE NOV 2 8 2023 <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 IV)AREON CUUN I <br /> www.co.marion.or.us/PWBuildin2Inspection BUILDING INSPECTION <br /> A.Property Owner Information <br /> . „- �.�� � �� � ��. � � yam. <br /> Robert&Nancy Bradford P.O. Box 691 <br /> Name Mailing Address <br /> Stayton,OR 97383 503-991-9985 or 503-507-5048 <br /> City, State,and Zip (Area Code)Phone# <br /> B.Legal Property Description ;,7 ,: r.. :' <br /> 110 Lake St. E. Detroit OR 97342 <br /> Property Address City State Zip Code <br /> T 10S, R 5E, Sec. 1CD 1300 <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: Hwy.22 east of downtown Detroit, left on Meyer St. S., immediate right turn into park. <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> fit' <br /> Exist. RV Park Up o 11 d'I RV connectionsOublic City of Detroit <br /> (aval a le area-dependent) Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ <br /> Seating Seating ❑ Private <br /> Well,Spring,Shared <br /> D.Type of Application <br /> Site Evaluation El Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement El Replacing a Dwelling <br /> El Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> El Major ❑ Minor El Existing System Evaluation ❑ Personal Hardship <br /> El Alteration Permit El Record Review ❑ Temporary Housing <br /> ❑ Major El Minor El 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 /> Brannon Lamp, REHS 503-922-2149 _ <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic. #(if applicable) <br /> 3439 NE Sandy Blvd.#165 Portland, OR 97232 brannon@aqua-resource.com <br /> Applicant's Mailing Address Email: <br /> 11/24/23 <br /> Signature Dat : CCB# (if applicable) <br /> Applicant is the ElOwner 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 />