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Application for Onsite Date Stamp: <br /> , _- Wastewater Treatment System <br /> - RECEIVE® <br /> MN, ' MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION AUG 08 2024 <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/BuildineInspection <br /> Operty t)wne forma iOn M`. .z. ..r .k _n, r w - �6 ...,l< ,w... <br /> Marilyn Hutchinson 49850 N Santiam Hwy <br /> Name Mailing Address <br /> Idanha,Oregon 97350 816-914-8647 <br /> Clty,State,and Zip (Area Cod)Phone# <br /> 49850 N Santiam Hwy Idanha OR 97350 <br /> Property Address City State Zip Code <br /> 10 6E 22 AD 01300 3.34 Acres <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property:N Santiam Hwy Past Idanha,Access Rd on Right,then left to address <br /> C stirs >±arcilit l'roposeiIxP ca'I�ty1.Wate I formatrouF _ ..' _ x. ..._�M. , , <br /> 2 h F 'vw.S-k4i', <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> ®Public <br /> 6c) Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees! Number of Employees/ El Private <br /> Seating Seating <br /> Well,Spring,Shared <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> x❑ Repair Permit El Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major 0 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 /> Micah Hozen dba New Creation Contracting 503-710-2565 38988 _ <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:\BUILDING INSPECTION\FORMS\SEPTIC\S-01 ONSITE APPL JULY 2023 REV 6.23.DOCX Rev 1/15,3/18,6/22,6/23 <br />