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Ev/'- <br /> Application for Onsite <br /> Date Stam <br /> „- _ Wastewater Treatment System {E C E 0 <br /> MARION COUNTY PUBLIC WORKS mOCT1JC 1 � � fin, <br /> 3 B <br /> BUILDING INSPECTION DIVISION � <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/BuildingInsnection <br /> A Property Owner Information' <br /> KINCAID, JAMES LEWIS, KINCAID, HEIDI INDIA 4136 FOREST RIDGE RD NE <br /> Name Mailing Address <br /> Silverton, Or, 97381 503-873-3003 <br /> City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> 15962 Stormy Dr NE Silverton OR 97381 <br /> Property Address City State Zip Code <br /> 071E06D002900 1.79 <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: Berry Meadows Lot 9 <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> ['Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms Number <br /> of Employees/ NumSeatberg of Employees/ ❑ Private Well <br /> Seain <br /> Well,Spring,Shared <br /> D Type of Application <br /> • Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ P• ermit Reinstatement ❑ R• eplacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ' ❑ Minor ❑ E• xisting System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major El Minor ❑ Other El C• onnecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> ❑ O• ther—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 /> Flow Line Construction LLC 503-871-2260 39474 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> 11805 State St. Salem Or, 97317 construction.flowline@gmail.com <br /> Applicant's ng Address Email: <br /> 10/11/23 239492 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the ❑Owner Q 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 />