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Application for Onsite For City Use Only: Date Stamp: <br /> Wastewater Treatment System city of ® E <br /> CEVI <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by J+JN 16 2023 <br /> 5155 Silverton Rd NE Fee MARION COUNTYSalem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# BUILDING INSPECTION <br /> www.co.marion.or.us/PWBuildin2lnsnection Activity# <br /> � a , v._.. ,A.Proper K.OvvnerInfonnatior „„ <br /> Angela Plowhead 4196 Roberts Ridge Rd S Salem, OR 97302 503-330-7109 <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> B:Legal Property Descriptio n a _. :. <br /> T8S;�R4W "Section f2D-8 Section t3P .�_ Tax Lot 1000&Tax Lot 101 6.09 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Roberts Ridge Proposed Parcel 2 <br /> Subdivision Name Lot Block <br /> 4176 Roberts Ridge Rd S Salem OR 97302 <br /> Property Address City State Zip Code <br /> Directions to Property: River rd to Riverdale to Petty John to Robert Ridge,second house to the end on the left <br /> :7 C.Existing Facility L¢Proposecl Facility!Water Information, <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence ❑ Single Fy Residence ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms ® Private well <br /> ® Other Septic for parcel 2 ❑ Other Well,Spring,Shared <br /> _' _ D T e of Application <br /> yP. <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 ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other ❑ 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 /> Angela Plowhead 503-330-7109 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 4196 Roberts Ridge Rd S Salem, Or 97302 <br /> Applicant's Mailing Address <br /> 6/2/23 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the Owner Authorized Representative Authorization to Apply form Attached <br /> PP ® ❑ P ❑ PP Y <br />