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— °g/i/-1Vrrn T <br /> 3 <br /> .diti `•",•. Application for Onsite For City Use Only: Date Stamp: <br /> -.- u Wastewater Treatment System City of -, <br /> Date Received RIC-E II YEM <br /> Received b <br /> MIMARION COUNTY PUBLIC WORKS y ..Zil <br /> BUILDING INSPECTION DIVISION Zoning by MAY 2 6 2023 <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 mARION COUNTY <br /> # RIJ'L D!NC!NCPE TI <br /> (503)588-5147 Fax(503)588-7948 Receipt .... _C,.QN <br /> www.co.marion.or.us/PW//BuildingInssvcction <br /> ('�ed? L Activity# <br /> n `L% / 6.®LC.'(tOb Prop" � er Information <br /> Matt Smith 5435 Swallowtail St SE Salem OR 97306 503-559-6724 <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> T8S: R3W: Section 29D 800 35.13 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> N/A <br /> Subdivision Name Lot Block <br /> 7905 Twin Fir Lane S Salem OR 97306 <br /> Property Address City State Zip Code <br /> Directions to Property: Liberty Rd S to Cole Rd, right on Cole, left on Twin Fir Lane S. Follow Twin Fir until it dead ends <br /> in cul-de-sac. Proceed up gravel driveway directly across cul-de-sac. Gate at top of driveway. Gate code=2020 SEND <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence © Single Family Residence Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms ® Private well(to be drilled) <br /> ® Other Pole Barn ❑ Other Well,Spring,Shared <br /> D.Type of Application • <br /> ❑ Site Evaluation ** ❑ Renewal Permit ['Authorization Notice for: <br /> X❑ 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 /> **Existing Site Evaluation Approval 555-23-002525-EVAL ❑ 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 /> Matt Smith 503-559-6724 N/A-self <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 5435 Swallowtail St SE Salem OR 97306 <br /> Applicant's ilin Add <br /> 3/27/2023 N/A <br /> Signs Date: CCB# (if applicable) . <br /> Applicant is the®Owner 0 Authorized Representative 0 Authorization to Apply form Attached <br />