Laserfiche WebLink
1 . <br /> Application for Onsite 'e1l <br /> Date Stamp: �✓ . <br /> Wastewater Treatment System <br /> 111111 MARION COUNTY PUBLIC WORKS ECENE t� <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE JUN 1 2 202k <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/BuildineInsvection <br /> A.:kioverty,Owner.-Infornation,: = N <br /> Brenda Moore & Al Unwin 450 N Santiam Hwy W <br /> Name Mailing Address <br /> Gates, OR 97346 <br /> City,State,and Zip (Area Code)Phone# <br /> B t-Le al Pro a escri tioa, <br /> 450 N Santiam Hwy W Gates OR 97346 <br /> Property Address City State Zip Code <br /> 093E27DA00400 13.86 <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> Lc_Existing acsh ty I Proposedu ac�lity`/Water Information �a <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> ❑•Public Gates City Water <br /> 1 MH/16RV Name <br /> Number of Bedrooms Number of Bedrooms Number Se <br /> of Employees/ Numb <br /> atinger of Employees/ <br /> El Private <br /> Well,Spring,Shared <br /> ,of A licaton, <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 ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> ❑■ Other—Please Specify <br /> Reconnect 1 Mobile Home and 16 RV spaces <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 /> Tyler Fuhriman 435-760-0717 W-10199358 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic. #(if applicable) <br /> 8727 SW 19th Ave I Portland, OR 97219 tyler@fuhrimanconsulting.com <br /> Applicant's Mailing Address Email: <br /> 4/30/2024 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the ❑Owner 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 />