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ads 7))\1 <br /> Application for Onsite Date Stamp: <br /> Wastewater Treatment System RECEIVED <br /> EMIMARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION APR 2 3 2024 <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/BuildingInspection <br /> ,A.:>P"roperty Ownerinforinatiori... —_ m — .._ _ ._ <br /> Ron Lee 6725 Skyline Rd S <br /> Name Mailing Address <br /> Salem, OR 97302 971-719-3127 <br /> City State and Zip • (Area Code)Phone# <br /> Ecop jiki escri'sttann, <br /> 6725 Skyline Rd S Salem OR 97302 <br /> Property Address City State Zip Code <br /> 083W19C 000400 7.13 Acres <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property:South on Commercial, rt on Liberty, Rt on Skyline 3 miles, Property is on Right <br /> ExiStitt Facxhty/PrQPosed tiii ity CWatei l iiottnaiiou <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> OPublic <br /> 4 Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ <br /> Seating Seating ® Private Well <br /> Well,Spring,Shared <br /> D .Type:ofApplicat�oa ` ._. <br /> ❑ Site Evaluation 0 Renewal Permit DAuthorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> O Repair Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation 0 Personal Hardship <br /> x❑ Alteration Permit ❑ Record Review 0 Temporary Housing <br /> 0 Major x❑ Minor 0 Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 0 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 503-710-25658 <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 0 Owner 0 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 />