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3a FAT <br /> : -- Appiicat cnt far Ons to For City tin aillq. r <br /> 3a Wastewater TT a eIIt.S:ystem City of <br /> ... <br /> C _V E <br /> Date Received E <br /> i M�IO _ <br /> I3tlll bING INFECTION DIVISION Zoning b <br /> IMMO ' MAY 2 2023 <br /> Zoning <br /> ' t 5155Stiverton?ItriNE Tee ' MARION COUNTY <br /> Salem 411 97345 <br /> f (5O))SSS 5147 Fa/(5e3)5/3$-7948 Receipt BUDDING INSPECTIO <br />• <br /> i `ti''' co marion:or us/PW/BtnIdiri11nspection Activity f€ <br /> A.:::Property Owner Information <br /> Name" Mailing Ad• d•ress Cit• y,State,: d Zip (Area Co( <br /> roperty Description <br /> f B`l.egal;I' <br /> Legal Description 3 Tax Lot Acreage or Lot Size <br /> • ot • Block?SU2 trf.,a0t .fit- • 12 <br /> PrapertyAddress City State Zip Co. <br /> Directions to Property: T <br /> • <br /> { C.Fxistttig Facility/Proposed Facility!Water Information <br /> Existing Facility: " ` Proposed Fat!liry: Water Supply: <br /> Osingle Family_Resiztence' �,.Smngle"Pa Residence blic LtD( -( <br /> 5 Name <br /> Number ofBedroom§"- Number of Bedrooms 9 0 Private <br /> © Other_ ❑ Other Well,Spring,S. <br /> � Y ei t5 D Type,"of Application'. . <br /> Site Evaluation 0• •Renewal_Permit AuthoriizationNatice for , <br /> ' ❑ Construction Permit ❑ ermitRetnstatement Rcplacrag:aDivelling(�t}c �U (,y;'j �,,{ <br /> d Repair Permit. ❑ 1'ermttTxransfer UTheeAddition-ofOneor More Bedr <br /> t� Major ❑ Miner ❑"Existing System Evaluation ❑°.Personal;Hardship <br /> Ei Alteration Permit ❑"Record Review" 0""T emporaryHousing <br /> ❑ Major 0 Minor ❑ Other' 0:Connecting to an Esistiug System I <br /> (over 5 yrsold) <br /> : ❑•Other .Please Specify <br /> • <br /> fj the required fee and attachments'are not inch!de!!with:this application it will be returned to you as incomplete. <br /> Post the orange'card at the entrance to theproperty �Fta >the tcst"tiol <br /> is By mysignature;I certify that the inforination.I have furnished is correct,and hereby grant County,authorizedDepartment of Environmental Quality,permission to enter onto"the above,described property far the,sole purpose of th <br /> 1"_.'tt hf...s S63,SBv�`(Ut2_" �t" <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number : . DBQLrc"ii (if applicable) <br /> P.n. anx IgCi ;({sz D 9732 , <br /> Applicant's Mailing Address <br /> tare Date. GCB rc (if applicable) <br />