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2L1_ Cqi, P i'i( <br /> Application for Onsite <br /> •,ii ,,,,� RECEDate Stamp: <br /> Wastewater Treatment SystemNED <br /> MARION COUNTY PUBLIC WORKS �� O <br /> BUILDING INSPECTION DIVISION Y 2024 <br /> 5155 Silverton Rd NE MARION COUNTY <br /> Salem OR 97305 BUILDING INSPECTION <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/P W/Buildinglnspection <br /> �,A.Property Owner Information _ _ __ <br /> ,—. iN\Q._ NIK: _016- -- 5\tAt V.XeOu6- Chr\ St; <br /> Name Mailing Address <br /> City, tate,and Zip _ (Area Code)Phone# _ _ _ <br /> ,B.Legal Property Description _ <br /> 314 OZ*-o \ c % _(` 6)\1661 2— <br /> Property Address City State Zip Code <br /> 17:\\I0-1 CAM\\00 5 '61 Ci . <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information _ <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> ❑Public <br /> 3 Name <br /> �t ` <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ ❑ private a \`\1 <br /> Seating Seating <br /> Well,Spring, Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> Construction Permit__VI...R.6p <br /> ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> it Pe t ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> inor ❑ Existing System Evaluation ❑ Personal Hardship <br /> AAlteration Permit El Record Review ❑ Temporary Housing <br /> KMajor ❑ 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 503-743-2343 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 /> di-ILL& 5110itil — 44551 <br /> Signature Date: CCB# (if applicable) <br /> C:\USERS\ANAJERASANCHEZ\APPDATA\LOCAL\MIICROSOFT\WINDOWS\INETCACHE\CONTENT.OUTLOOK\3T7CT1Q3\S-01 ONSITE APPL JULY <br /> 2023 REV 6.23.DOCX Rev 1/15,3/18,6/22,6/23 <br />