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Date Stamp: <br /> For City Use Only: n�vApplication for Onsite City of .' E C n �7 <br /> a AT stem D Received 11 �l <br /> .� Wastewater Treatment Sy ' 1 <br /> Received by�— MAY 1.5 2023 I <br /> 111111/ BAILOR COUNTY PUBLIC WORKS Zoning by <br /> BUILDING INSPECTION DIVISION md��`el�l�l'� COUNTY' <br /> Silverton.Rd NE Fee <br /> Salem OR97305 Receipt# B ILDING INSPECTION <br /> (503)588 5147 Fax(503).588-7948 Activity# <br /> www.co .us/PW/Buildin¢'lusDechun <br /> A.Property Owner Information <br /> 447 State St Salem,OR 97301 <br /> 503-932 8785 <br /> Glen Kent-715 River Road LLC ]---- ng Address City,State' <br /> and Zip (Area Code)Phone.# <br /> Name B.Legal Property.Description a2s Ac. <br /> 093E26CCO260� Acreage or Lot Size <br /> Tax Lot <br /> Legal Description <br /> 2600 <br /> Subdivision Name Lot Block <br /> 97346 <br /> Gat____ _____---_ State Zip Code <br /> t00 E Central Ave City <br /> Horeb St.and it is on your left <br /> Property Addressthrough gates,take a right on <br /> . Headed East 9 9 <br /> 'reckons to Property. <br /> C.Existing Facility/Proposed Facility/Water Informationter Supply: <br /> Existing Facility: Proposed Facility: Wa2 City of Gates <br /> 2 <br /> Number ofBedrooms <br /> le Family Residence ® ®Public Single Family Residence Name <br /> • g <br /> Number of Bedrooms <br /> ❑.PrivateWell,Spring,Shared <br /> D.Type ofPP <br /> Other None ❑ Other <br /> ® Application <br /> .., <br /> al Permit ®Authorization Notice for: <br /> ❑ Site Evaluation ❑ Renew ®Replacing a.Dwelling <br /> ❑ Construction Permit 0 Permit Reinstatement <br /> ❑ Repair Permit 0 Permit Transfer ❑ The Addition of One or More Bedrooms <br /> 0 Major 0 Minor 0 Existing System Evaluation 0 Personal HardshipID Temporary Housing <br /> ❑ Alteration Permit ❑ Record Review <br /> 0 Connecting to an Existing System Never in Use <br /> ❑ Major 0 Minor ❑ Other (over 5-yrs old) <br /> 0 Other—Please Specify <br /> If the required 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 /> Byinformation I have furnished is correct,and hereby grant Marion County,authorized agent o the <br /> thatthethis application. <br /> my signature,I.certify property <br /> Department of Environmental Quality,permission to enter onto the above describedfor the sole purpose of <br /> Greg Clinton-Clinton Construction Inc. 503-871-4764 39d98Lic.# (if applicable) <br /> Applicant's Name DEQ Please Print Legibly Applicant's Phone Number <br /> P.O. Box 128 Scio,OR 97374 <br /> Applicant's Mailing Address <br /> Si a Date: <br /> � 5/4/2023 225149 <br /> , �y� CCB# (if applicable) <br /> Applicant is the❑Owner ®Authorized Representative 0 Authorization to Apply form Attached <br /> F:\FORMS\SEPTICIS-01 ONSITE APPL SEPT 2022.DOCX Rev 1115,3/18,6/22 <br />