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Z 3-Oo72((Q- to kin I <br /> y ,* . Application for Onsite For City Use Only: Date Stamp: <br /> Wastewater Treatment System <br /> City of <br /> mi------, <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by J <br /> BUILDING INSPECTION DIVISION Zoning by _J <br /> 5155 Silverton Rd NE AUG 2 2023 <br /> Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# MARION COUNTY <br /> www.co.marion.or.us/PW/Buildinglnspection Activity# BUILDING INSPECTION <br /> A Property Owner Information <br /> Andres Hildago 3012 Mooreland Ave NE Salem, OR 97035 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> 082W16A001700 _ ' 1.05 _. <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 6450 S Aumsville Highway SE Salem OR 97317 <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information; <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence M Single Family Residence ['Public <br /> 5 Name <br /> Number of Bedrooms Number of Bedrooms U Private Well <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D.Type of Application <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 /> O 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 /> 4 s-AC o L-LG SO3 I- I' .316AL <br /> Ap ic t's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Lies SU-.AJ 0 1 ,) E �$CI\ O1( c� Q5 <br /> Applicant's ailing e <br /> iii9--,,,z3-zo).3 2-3543 iG <br /> S- Dale: CCB# (if applicable) <br /> Applicant is the❑ Owner - uthorized Representative ❑Authorization to Apply form Attached <br />