Laserfiche WebLink
, � 1 Application for Onsite Da.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(5O3)588-7948 <br /> www.co.marion.or.us/PW/Buildinginspection <br /> A.Property Owner Information <br /> kres S hoe-key I MS' t t, t( P,.-r„n t tom-( SE_Name ( Mailing Address <br /> S�t4441 ,a R. et-z3/-7 <br /> City.State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> Hekuat Pre,vit_ sE wt F OtZ.. ei7Si7 <br /> Property Address City State Zip Code <br /> C `1 tZL 3t9C ab 134,u 1'300/1R6e-, 4.11 Li 3 <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> ❑Public <br /> 5 5t4+S Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/2C vt a/ <br /> Sealing Seating Private <br /> eC -(3�s�d ca Well,Spring,Shared <br /> D.Type of Application Sw wc�c `+ Da sP'r"'t e,fe. <br /> (s Site Evaluation 0 Renewal Permit ❑Authorization Notice for: <br /> Construction PermitPermit Reinstatement Replacing a <br /> ❑ 0 ❑ P 8 Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer 0 The Addition of One or More Bedrooms <br /> ❑ Major 0 Minor 0 Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit 0 Record Review ❑ Temporary Housing <br /> ❑ Major 0 Minor 0 Other 0 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 he 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 /> Oregon Sewer & Drain LLC 503-874-9414 38968 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic. #(if applicable) <br /> PO Box 1282 Silverton. OR 97381 josh@oregonsewer.com <br /> Applicant' ail' Addr Email: <br /> 201683 <br /> S" ature Date: CCB# (if applicable) <br /> Applicant is the ❑Owner IN Authorized Representative(form attached) <br /> G:\BUILDING INSPECT1ONIFORMS%SEPTIC1S-01 ONSITE APPL JULY 2023 REV 6.23 DOCX Rev 1/15,3/18,6/22,6/23 <br />