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2f-00 3 Z9(' AtiTI} <br /> Application for Onsite Date Stamp: <br /> Wastewater Treatment System R C v <br /> MARION COUNTY PUBLIC WORKS —J <br /> BUILDING INSPECTION DIVISION APR 2 6 2024 <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 MARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 BUILDING INSPECTION <br /> www.co.marion.onus/PWBuildinaInsnection <br /> A.Property Owner Information <br /> Thomas and Roxiellia Burns 2611 Jory Hill Rd S <br /> Name Mailing Address <br /> Salem, Or 97306 (503) 949 2798 <br /> City, State,and Zip__. (Area Code)Phone# <br /> B.Legal Property Description <br /> 2611 Jory Hill Rd S Salem OR 97306 <br /> Property Address City State Zip Code <br /> 083W20B 001400 2.10 <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: South on Liberty S from Salem center, right on Jory Hill Rd <br /> C_Existing Facility/Proposed Facility/Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> 4 ADU 3 Main ['Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ 1:1 Private Well <br /> Seating Seating <br /> Well,Spring,Shared <br /> D.Type of Application r_ <br /> ❑ Site Evaluation ❑ Renewal Permit Authorization Notice for: <br /> ❑ Construction 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 /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor ❑■ Other Authorization ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> El 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 /> Kiel Brown (503) 362-7000 39705 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic. #(if applicable) <br /> 40110 Providence Dr. Scio, Or 97374 OnsiteEx541@gmail.com <br /> Applic is Mailing Address Email: <br /> 4/24/2024 OR 250476 <br /> Signature Date: CCB# (if applicable) <br /> CAUSERS\ANAJERASANCHEZ\APPDATA\LOCAL\MICROSOFT\WINDOWS\INETCACHE\CONTENT.OUTLOOKTICJL2DXTIS-01 ONSITE APPL JULY <br /> 2023 REV 6.23.DOCX Rev 1/15,3/18,6/22,6/23 <br />