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d3-t5b -T15 <br /> Application for Onsite <br /> Date Stamp: <br /> --=— Wastewater Treatment System <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION J V LS <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 NOV 29 2023 <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PWBuildingInspection MARION COUNTY <br /> BUILDING INSPECTION <br /> A.Property Owner Information _ <br /> Greg Brown 5501 Lipscomb Street SE <br /> Name Mailing Address <br /> Salem, OR 97317 503-368-8441 <br /> City, State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> 5501 Lipscomb Street SE Salem OR 97317 <br /> Property Address City State Zip Code <br /> ZD®?t fl tbA0-1) <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> ❑Public <br /> 3 4 Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ Private Well <br /> Seating Seating <br /> Well, Spring,Shared <br /> D.Type of Application <br /> El Site Evaluation ❑ Renewal Permit Authorization Notice for: <br /> El Construction Permit El Permit Reinstatement 0 Replacing a Dwelling <br /> El Repair Permit ❑ Permit Transfer El The Addition of One or More Bedrooms <br /> El Major El Minor El Existing System Evaluation ❑ Personal Hardship <br /> El Alteration Permit El Record Review El Temporary Housing <br /> El Major ❑ Minor El Other El 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 /> Sam Mikolasy 509-991-2573 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lie. #(if applicable) <br /> 1280 Fir Street S, Salem, OR 97302 sam@skyline-co.com <br /> Applicant's Mailing Address Email: <br /> 11/28/23 _ 234226 <br /> Signa r- Date: CCB# (if applicable) <br /> Applicant is the El Owner III 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 />