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aL\ 515'� <br /> Application for Onsite Date Stamp: <br /> - ., Wastewater. Treatment System <br /> mgMARION COUNTY PUBLIC WORKS RECEIVED <br /> BUILDING INSPECTION DIVISION JUL 0 3 2024 <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co-marion.orms/PW/Buildinginsoection <br /> A.Prope ty O, eginformatioi s <br /> .fi t pag-, 43 go,vist, a4pn ,s <br /> Name Mailing Address <br /> '��vli-r t 0 le <br /> cr7 Z <br /> City,State,and Zip (Area Code)Phone# <br /> $...Ie�? kiiii el DescrrptIon ,; <br /> V., 4:1 G sLA_ iZet.SE Wit: 4,- o?2 9-739 <br /> Property Address City State Zip Code <br /> d'Z&.Ze5 p®a1 G i'500 l It 49, <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> ,f.0 Existmg'wFaeilityrn/Proposed Facility 1: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 ofEmployees/ Number of Employees/ gi Private Well <br /> Seating Seating <br /> Well,Spring,Shared <br /> :;D‘Type of App ratio <;. ... ,. <br /> ❑ Site Evaluation 0 Renewal Permit ['Authorization Notice for: <br /> Construction'Permit ❑ Permit Reinstatement 0 Replacing a Dwelling <br /> pRepair Permit ❑ Permit Transfer 0 The Addition of One or More Bedrooms <br /> 0 Major '® Minor ❑ Existing System Evaluation 0 Personal Hardship <br /> 0 Alteration Permit 0 Record Review 0 Temporary Housing <br /> ❑:Major °❑ Minor 0 Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> il- Rep 1t4L. bz.jC:t3 T44,,y <br /> k 0 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 vrange.card at the entrance to the property. Flag the test holes. <br /> By my signature,,I certify that the information 1 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' a' ' Addres Email: <br /> —7-3-2q 201683 <br /> "gna Date: CCB# (if applicable) <br /> Applicant is the 0 Owner IN Authorized Representative(form attached) <br /> G:\BUILDING INSPECTIONIFORMS\SEPTIC\S-0I ONSITE APPL JULY 2023 REV 6.23.DOCX Rev 1/15.3/18,6/22,6/23 <br />