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di-l-tbuibc\5 <br /> • Application for Onsite Data Stamp: <br /> Wastewater Treatment System <br /> Y RECEIVE* <br /> 1111111-7 MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION AUG 05 2024 <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/BuildingInsnection <br /> A Pro er Owner Information <br /> Kyle Gulstrom I Foodology Mobile Kitchen LLC 11343 Branch Ln SE <br /> Name Mailing Address <br /> Stayton, OR 97383 503-881-9874 <br /> City,State,and Zip (Area Code)Phone# <br /> r B Leg_a1.Property,llescription r.., r 1 <br /> 22935 Jennie Rd NE Lyons OR 97358 <br /> Property Address City State Zip Code <br /> 092E18AD01000 0.85 <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> [ C Ex�stmgacil�ty/I'roasedEacilit!`Wate .fnDformataon = .._ :.'H_..._. <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> 600 GPD 750GPD ❑■Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ <br /> Seating Seating ❑ Private <br /> Well,Spring,Shared <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ❑ 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 El Personal Hardship <br /> ❑ Alteration Permit El Record Review ❑ Temporary Housing <br /> El Major ❑ Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> ❑■ Other—Please Specify <br /> Increase in flow I Adding Coffee food cart to existing system. <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 /> Tyler Fuhriman 435-760-0717 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic. #(if applicable) <br /> 8727 SW 19th Ave I Portland, OR 97219 tyler@fuhrimanconsulting.com <br /> Applicant's Mailing Address Email: <br /> Tom+— — 8/2/2024 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the ❑Owner ❑■ 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 />