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. 2.3-o a o3s a-ot-t-i- <br /> • <br /> .• <br /> Application for Onsite . For City Use Only: Date Stamp: <br /> Wastewater Treatment System City of - • <br /> .1111 <br /> Date Received <br /> • <br /> MARION COUNTY PUBLIC WORKS • , <br /> Received by <br /> • BUILDING INSPECTION DIVISION Zoning by RE IC E V T1) <br /> _I:9 <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 • . <br /> (503)588-5147 Fax(503)588-7948 Receipt# • MAY 12 2023 <br /> • Activity# <br /> wvvw.co.marion.or.us/PW/BungInspectioa MARION COUNTY <br /> - <br /> . . . ... . 13UILDINaINSP.ECTION <br /> Kelly Webb 15932 Stormy Dr. NE Silverton, OR 97381 911-239-8627 <br /> • <br /> Name Mailing Address City,State,and.np • , (Area Code)Phone# <br /> -. , . <br /> i .... -; • .- . • __. -.. . . ! .. . B.Legal Propert y DeFFiptipn. . • . • <br /> _ .. -,_• _ . •• <br /> ' 1 5 Artres. <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Berry Meadows . 1 0 • • <br /> - <br /> Subdivision Name Lot - Block • <br /> • , . <br /> 15932 Stormy Dr. NE • Silverton OR 97181 <br /> Property Address City State Zip Code • • <br /> Directions to Property: Hwy 214 from city of Silverton, Turn left on Forest Ridge Rd. SE, Turn Right <br /> • on Stormy Dr. NE, Property is 1st on right at intersection_ <br /> i'------------.7-777-7----7.---6.-tl-altilifiaiiiiiiii-OFiec—FriaitiiiThifeilaii;iiiia--------'77-7-7-7---1 <br /> Existing Facility: Proposed Facility: Water Supply: <br /> NSingle Family Residence .0 Single gamily Residence ['Public • <br /> . <br /> 3 Name <br /> Number of Bedrooms . Nunibei fBedrooms 2 A . ate <br /> EI Other - CI Other Well, '9 •,I Shared <br /> i. ,:- • , • . ' -% - .. - -• •-; - - • . D.'Pip of Appiicati,,pn •••• — --•- . •.1. ' • '1.......00 • . - I <br /> i <br /> El Site Evaluation 0 Renewal Permit NAuthorization Notice for: <br /> 0 Construction Permit 1:1 Permit Reinstatement ' . 0 Replacing a Dwelling ' <br /> • <br /> 0 Rank Permit El Permit Transfer El The Addition of One or More Bedrooms <br /> [] Major 0 Minor • 0 Existing System Evaluation II Personal Hardship <br /> El Alteration Permit 0 Record Review 0 Temporary Housing • <br /> 0 Major 0 Minor D Other El Connecting to an Existing System Never in Use <br /> - (over 5-yrs old) <br /> 0 Other—Please Specify . <br /> " . <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 /> Kelly Webb . 971-239-8627 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> . • . <br /> 15932 Stormy Dr. NE, Silverton, OR 97381 • <br /> Applicant' M • • g Addr . <br /> ... • <br /> kr e sii Aez 3 . <br /> Sip.: e Date CCB# (if applicable) <br /> • <br /> . • <br /> Applicant is the[-.0 Owner 0 Authorized Representative 0 Authorization to Apply form Attached <br /> GAPORMS‘SEPTIC1S-01 ONSITE APPL SEPT 2018.DOCX Rev 1/15,3/18 <br />