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3-bo6aL\\ <br /> Application for Onsite For City Use Only: Date Stamp: <br /> Wastewater Treatment System City of <br /> Date-Received <br /> MARION COUNTY PUBLIC WORKS Received by „ D ECEOVE <br /> BUILDING INSPECTION DIVISION Zoning by I <br /> 5155 Silverton R4 NE Pee <br /> Salem OR 97305 (UN 15 2023 ----j <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> . <br /> wwvV.co.indrion.ot.us/PW/Buildinehisuection ActIv'ty 4 MARION COUNTY <br /> ' - ' BUILDING INSPECTION <br /> A.ProPertyOwner Information <br /> Ferschweiler Intermodal, LLC 6800 Le Brun Road NE Woodburn,Oregon 97071 503-371-301a <br /> Name Mailing Address , City,State,and Zip (Area Code)Phone# <br /> B.LegalPropertynakription <br /> set 15,T5S, FI2VV,W.M. 500&700 18.49 ac <br /> Legal Description Tax Lot Acreage or Lot Size <br /> N/A N/A :N/A <br /> Subdivision Name Lot Block <br /> 6800 Le Brun Road NE Woodbum OR 97071 <br /> Property Address City State Zip Code <br /> Directions to property: From 1-5 south turn.left on Hillsboro-Silverton Hwy NE,turn left on Butteville Rd heading south, <br /> turn right on Le Brun Rd NE,head west for approximately 1.4 miles the site will be on your left hand side <br /> C.Existing Facility I Proposed:Facility 1Water Information <br /> Existing Factiity: Proposed Facility: Water Supply: <br /> 0 Single Family gesicignce 0'Single Family Residence Opublic <br /> Name <br /> Number of Bedrooms Number of13edroorns 0 Private Well' <br /> 0 Other Farm Field n Other Commercial Well,Spring,Shared <br /> D.Type of Application , - <br /> ci Site Evaluation 0 Renewal Permit 0Authorization Notice for: <br /> O Construction Permit 0 Permit Reinstatement 0 Replacing a Dwelling <br /> O Repair Permit- 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> O Major 0 Minor D Existing System Evaluation D Personal Hardship <br /> O Alteration Permit 0 Record Review 0 Temporary}lousing <br /> O Major D Minor El Other 0 Connecting to an Existing.System Never in Use <br /> (Over 5-yrs old) <br /> 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 theotange card at the entrance tci.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:ate <br /> Departrnent.of Bnvironmeritg Quality,permission to enter onto the above described property for the sole pnrpost of this-application. <br /> Tyler Roth 503-400-60213 <br /> Applicant's Name—Please,Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 3700 River Road N., Suite 1 <br /> Applicant's Mailin Adtires4 <br /> 05-30-2023 <br /> Si hire Date: CCB# (if applicable) <br /> Applicant is the D owner. 0 Authorized Representative E Ailthorizatiori.to Apply form Attached <br /> VAEORMS‘SEPTIC\S-OI ONSITEAPPL SEPT 2022330CX Rev 1/15,3/18,6/22 <br />