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DocuSign Envelope ID:43306CDE-421A-4D2B-94DB-9445E9522951 <br /> Application for Onsite 073 r6)°(07� <br /> q1 <br /> ---r � ., Wastewater Treatment System D ECE VarD <br /> MARION COUNTY PUBLIC WORKS AUG 0 9 2023 <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE MARION COUNTY <br /> Salem OR 97305 BUILDING INSPECTION <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/Buildin2Insnection <br /> A Pra ertyf Owner;I`nformation <br /> Wood Structure components NW LLC. 445 Salem Heights Ave S <br /> Name Mailing Address <br /> Salem, OR. 97302 503-793-4304 <br /> City,State,and Zip (Area Code)Phone# <br /> 12061 HAPPY WAY SE JEFFERSON OR 97352 <br /> Property Address City State Zip Code <br /> 1900 093W14D001900 2.28 acr. <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: from JEFFERSON HWY SE go east on STEIWER RD. right/south on HAPPY <br /> WAY SE. lot 2 on the right <br /> EausttngwFacJityY'1 'roposed Facility/Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> 0 4 6 0 ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ well <br /> Seating Seating ® Private <br /> Well,Spring,Shared <br /> D.Type of Appljcatwn .__ _._ —57 �.�. 2 7:1 <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ❑X 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 /> Logan Benjamin 503 884 6296 39191 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic. #(if applicable) <br /> PO BOX 670 Lyons OR. 97358 groundbreakingexc@gmail.com <br /> Applica is ai Address Email: <br /> ��i� 09/08/2023 219731 <br /> S1gnhu A49A635E3D4B5... 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 />