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Application for Onsite For City Use Only: Date Stamp: <br /> City of <br /> �3 Wastewater Treatment System f <br /> .......,...ai <br /> Date Receivedn 5,c <br /> F-1 <br /> MARION COUNTY PUBLIC WORKS Received by J <br /> 16 <br /> BUILDING INSPECTION DIVISION Zoning by �vU2022 <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 MARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 Receipt# BUILDING INSPECTION) <br /> www.co.marion.or.us/PW/BuildingInspection Activity# <br /> ' A.Property Owner Information <br /> Dale Smith 8028 Jorgensen Ln SE Salem, OR 97317 503-576-0206 <br /> Name Mailing Address City, State,and Zip _ (Area Code)Phone# <br /> B.Legal Property Description <br /> 082W1-1 D --- - 03000 .2.25Ac <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 8028 Jorgensen Ln SE Salem OR 97352 <br /> Property Address City State Zip Code <br /> Directions to Property: Follow 1-5 N and OR-22 E to Joseph St SE.Take exit 5 from OR-22 E.Turn left on Jordan St,then left on 71st <br /> Turn left back onto Jordan St and follow to Jorgensen Ln <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ['Single Family Residence 12 Single Family Residence ❑Public <br /> vl Name U��/y <br /> Number of Bedrooms Number of Bedrooms xi Private IJ <br /> ❑ Other ❑ Other Well, Spring,Shared <br /> D.Type of Application _ <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> El 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 /> Jesus Andrade/3-A Construction, LLC. 971-218-3568 39002 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 1690 Harvey ST SE, Jefferson OR 97352 <br /> Applicant's Mailing Address <br /> c. ,i///1 10/03/2022 167959 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner El Authorized Representative 0 Authorization to Apply form Attached <br />