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G9LI- oode) <br /> Application for Onsite Date Stamp: <br /> Wastewater Treatment System <br /> 11111. MARION COUNTY PUBLIC WORKS RECEIVED <br /> BUILDING INSPECTION DIVISION MAR 27 2024 <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PWBuildingInspection <br /> A:I'rapertyOwnerInformation 7 7_.,71 <br /> Stacey Stemach 1305 NW Fresno Ave <br /> Name Mailing Address <br /> Bend,OR,97703 541-390-5134 <br /> City, State,and Zipmm (Area Code)Phone# <br /> ,,BegaIProperty;pescrtiam ,.., <br /> 10351 N Fork Ln SE Lyons OR 97358 <br /> Property Address City State Zip Code <br /> 09 03E 11BB 02200 0.75 <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: S.on Jefferson Hwy 99E from 1-5, 1-1/4 Miles, Property is on left <br /> I CA:r sttn Faciliiy!Proposed Facility%Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> A. c't7Dn-, ['Public <br /> ? (Fire Destroyed) 3 Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ ® Private Well <br /> Seating Seating <br /> Well,Spring,Shared <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> El Construction Permit El Permit Reinstatement ❑ Replacing a Dwelling <br /> ID Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑X Major ❑ Minor El Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review El 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 /> Micah Hozen dba New Creation Contracting 503-710-2565 �38598j� — <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 /> 3/27/24 201065 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the ❑Owner ❑x 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 />