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, .14- 15i)Le5rd\ <br /> Application for Onsite Date Sump: <br /> � Wastewater Treatment System RECEIVED <br /> iiiiMARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION AUG 16 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/Buildingjospection <br /> :1, o e O ner'Tnfornia#01 <br /> 13vu51A IL_ P/4 5 Pei 13 -Ili <br /> Name ' Mailing Address <br /> 5111ir,'t, , a C r/361 <br /> City,State,and Zip (Area Code)Phone# <br /> B .egal Property Description _... _. - <br /> 1155- .fir'tG - tt1E St 1 -- . ne. ct73g( <br /> Property Address City State Zip Code <br /> ri t h.re c1 ,e5 C.r) 0'0 6 51' Irre-1 S <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> C.Existimg 1 aciliii y/Pr'oposed Facility r Water.Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> 9Q ` ['Public( Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ p t(� - <br /> SeatmgW Seating ® Private ,rLre .s c <br /> ivr,G p,--4ywr,-5.. (P- ts� r Y4vhr e p g, hared '��`-k <br /> fx Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> El Construction Permit ❑ Permit Reinstatement 0 Replacing a Dwelling <br /> ❑ Repair Permit- ❑ Permit Transfer 0 The Addition of One or More Bedrooms <br /> ❑ Major 0 Minor ❑ Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit 0 Record Review 0 Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other 0 Connecting to an Existing System Never in Use <br /> ,, --1, Ptifel- (over 5-yrs old) <br /> 4 / s J^ Flock (�P 44uvw y i^t�►lact t a,ti,1„J,,(t_.�rrc(G7' ' ❑ Other-Please Specify <br /> If the requiredfeeand 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 /> Oregon Sewer& Drain LLC 503-874-9414 38968 <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic. #(if applicable) <br /> PO Box 1282 Silverton. OR 97381 josh@oregonsewer.com <br /> Applicant's'. T§ Addr Email: <br /> l 1 1•o4/ 201683 <br /> S' a e Date: CCB# (if applicable) <br /> pplicant is the 0 Owner IN Authorized Representative(form attached) <br /> G:\BUILDING INSPECTION\FORMS\SEPTIC\S-01 ONSITE APPL JULY 2023 REV 6.23.DOCX Rev 1/15,3/1.8,6/22,6/23 <br />