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J14-(5b752D(-Q\ <br /> Application for Onsite Date Stamp: <br /> Wastewater Treatment System <br /> wl <br /> - _ECEOVE ' <br /> MARION COUNTY PUBLIC WORKS rn <br /> BUILDING INSPECTION DIVISION p <br /> �� 30 �d' <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 Tt�AN��� C(�lJi 'fY <br /> (503)588-5147 Fax(503)588-7948 B U i LD IN <br /> ( I NI sOpUE <br /> www.co.marion.or.us/PW/BuildingInsnection <br /> A.Property Owner Jqformation <br /> DOv y i.f ®ut s5 111117, L,'�a� p 4I0-6 <br /> Name Mailing Address <br /> =5� e•ilot a � — 2c— iv6 <br /> City,State,and Zip (Area Code)Phone# <br /> • <br /> B.Legal Property Description <br /> Property Address City' State Zip Code <br /> 0e W 1,9Coo21®a e <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: ;13- .�� . (, �— � ,� ',,rei9 r,.¢=_ CO , <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> ['Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ L Priva e ��/ <br /> Seating Seating �/l/ <br /> 4410 Spring,°Shared <br /> D.Type of Application _ <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> 11.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 ❑ 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 /> Bethel Excavating 5037432343 36198 <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic. #(if applicable) <br /> PO Box 504 Turner OR 97392 office@bethelexc.com <br /> Applicant's Mailing Address Email: <br /> ` \\ LlZ1/Z 1 445 <br /> 51 <br /> Sig3PQ_ <br /> Date: CCB# (if applicable) <br /> C:\USERS\ANAJERASANCHEZ\APPDATA\LOCAL\MICROSOFT\WINDOWS\INETCACHE\CONTENT.OUTLOOK\3T7CTIQ3\S-01 ONSITE APPL JULY <br /> 2023 REV 6.23.DOCX Rev 1/15,3/18,6/22,6/23 <br />