Laserfiche WebLink
(9,14-1(5-b3Pcd-- <br /> Application for Onsite Date Stamp: <br /> Wastewater Treatment System <br /> 111.111 MARION COUNTY PUBLIC WORKS RECEIVED <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 APR 15 2024 <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PWBuildingInspection <br /> A. ropert OwneaInforat<on..: . �... _w_.. <br /> Scott Henry 3868 Riverdale Rd.S <br /> Name Mailing Address <br /> Salem,OR 97302 503-327-5563 <br /> City,State,and Zip (Area Code)Phone# <br /> Legal Property escription, . ,. <br /> 3868 Riverdale Rd.S Salem OR 97352 <br /> Property Address City State Zip Code <br /> 083W06DC 00900 3.34 Acres <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property:River Rd S.,3.5 miles then left on Riverdale Rd.S, Property is 0.1 miles down on left <br /> C_E sang Facili l Proposed,Fac►l A714 Water InformationtH,_ y _ <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/ <br /> Seating Seating ® Private Well <br /> Well,Spring,Shared <br /> .U.?1'yp�ofApPlicattoa_ _._ ._.._ <br /> ❑ Site Evaluation El Renewal Permit ❑Authorization Notice for: <br /> 11 Construction Permit Ei Permit Reinstatement Ei Replacing a Dwelling <br /> x❑ Repair Permit El Permit Transfer ❑ The Addition of One or More Bedrooms <br /> © Major ❑ Minor El Existing System Evaluation ❑ Personal Hardship <br /> El Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor El 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 38898 3 F>0\sfae <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 s Email: <br /> 201065 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the ❑Owner ❑x Authorized Representative(form attached) <br /> G:\BUIL.DING INSPECTION\FORMS\SEPTIC\S-01 ONSITE APPL JULY 2023 REV 6.23.DOCX Rev 1/15,3/18,6/22,6/23 <br />