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9 4 -v.4 <br /> Application for Onsite Date Stamp: <br /> Wastewater Treatment SystemRECEIV ER <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION 14 202k <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PWBuildingInspection <br /> A Property Owner Information <br /> Andrey Kaya 19965 Butteville Rd NE <br /> Name Mailing Address <br /> Hubbard, OR 97032 5039517887 <br /> City,State,and Zip (Area Code)Phone# <br /> B:Legal Property'Description <br /> 9584 Fisherman Ln NE Aurora OR 97002 <br /> Property Address City State Zip Code <br /> LOTS ?j <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 /> 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 /> ❑� Site Evaluation El Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit El Permit Reinstatement El Replacing a Dwelling <br /> El Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major El Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> El Alteration Permit ❑ Record Review El Temporary Housing <br /> ❑ Major El 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 /> Andrey Kaya 5039517887 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> 19965 Butteville Rd NE andrey_kaya@outlook.co <br /> Applicant's Mailing Address Email: <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the ❑■ Owner El Authorized Representative(form attached) <br /> HTTPS://MARIONCOUNTYGCC-MY.SHAREPOINT.COM/PERSONALBREICH_CO_MARION_OR_US/DOCUMENTS/DESKTOP/S-01 ONSITE APPL <br /> AUGUST 2024 REV 8.24.DOCX Rev 1/15,3/18,6/22,6/23,8/24 <br />