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2&I- ODIcg( pg T" <br /> Application for Onsite Date Stamp: <br /> Wastewater Treatment System Ic -v --_-_, <br /> Illig- *'''''''''- - . <br /> MARION COUNTY PUBLIC WORKS �/ <br /> BUILDING INSPECTION DIVISION MAR 01 2024 <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 MARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 BUILDING INSPECTION <br /> www.co.marion.or.us/PW/Buildin2bispection <br /> 4 A Property_Owner Information ,4 W F ` <br /> -\ —e. Din 1- .. 41i2t eI y.ce i Q ei P R S <br /> Name Mailing Address <br /> S4i&en OR sae SIZPclr - % ? <br /> City,State,and Zip (Area Code)Phone# <br /> t B Legal P roperty Descnption n f <br /> Property Address City State Zip Code <br /> Parcel# nn Tax Lot ��,� (Acreag or Lot Size <br /> Directions to Prope �=co i 7 d ,,, &e - ete, 4— • /l fir,-ta, t r -0,i d <br /> Q on Ave_ ),.1 moo,,ort C '4.A, 9"Gtt.c ( R Exct�� <br /> C Ensting Facility/Proposed Facility/Water.Information .< ' . <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/ �1 Private ti 1' <br /> Seating Seating <br /> ACP <br /> Spring,Shared <br /> D Type;of_Application . . . ._ . . :''.. <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> IR) 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 /> 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 5037432343 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 lVjAdd/ress Email: <br /> 6-A�/t 3111211 44551 . <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 />