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a 6b Li a <br /> RECE [NE 3- <br /> , __) <br /> AUG 012023 <br /> 44.,. . Application for()mite For ar Use Mir MAP I 04 U NTY • <br /> --_=:. ,. Wastewater.Treatment System ` `°` .BUILDING INSPECTION <br /> Dale Received <br /> 1 <br /> MARION COUNTY PQBI3C WORKS 'Received by <br /> BUILDING INSPECTION•D[VISION • Zoning by. <br /> •51555 Siivertea Rd NE 'Fee 1 <br /> Sales OR 97303 <br /> (503)588=5147 Fax(503)'588-7948 Receipt# 1 <br /> www.r.o.marion,orant/PW/BuildEngtmnecilon <br /> Activity# <br /> 1 <br /> CYwde, c,b If e(rlyrtef4,i. 333) (?aler t-. lti Srt(ebiOte Q73C1 ( 503•-r 1—7bi71( <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> --- . •• B;•Legal.v.�......,ri.......�t::ritln _ l- <br /> • . <br /> 7 lE y c 1 a.e./ 1, 5 es <br /> Legal Description . Tax mot Acreage or•Lot Size <br /> Subdivision Nome Lot clock <br /> 15i V, 0 ctnei 24 Nj..: S;jvd/(iur, 0'Q. 7/�735 <br /> Property.Address. City State Zip Code <br /> fireetioas to Property: • <br /> Exults FeFlik: Pzopeeed Facility: Water Sappy: <br /> [ iogle.Famtky Residence ❑ Single Family Residence ❑Palilic <br /> Name <br /> Number of Bedrooms Number of Bcdmoms Fe Private <br /> ❑ Other 0 Other Well, ;piing,Shared <br /> - : . D.TypeofApplication' . . . . . .. <br /> , ❑ Site Evaluation 0 Renewal'Permit ❑Aed:miaatlon Notice for: , <br /> ____..0 ction Permit 0 Permit Reinstatement - ❑ Replacing a Dwelling <br /> J Permit 0 Permit Transfer 0.The Addition of One or More Bedrooms <br /> D Major door 0 Existing System-Evaluation 0 Personal Hardship <br /> ❑ Alteration.Permit 0 Record Review 0 Tar:Wary Housing <br /> .❑ MaJor 0 'Minor 0 tither ❑ Connecting to an Existing System Never in Use <br /> (over 3-yrs old) <br /> 0 Other-Please;Specify <br /> lithe required fee and attachments are not included with this application it will be rretekned to you as bowl plete. <br /> Post the orange card at the entrance to the property. Flag the test holes. 1 <br /> By my signature,i certify that.the:tnformation I have fiitnlsbed is correct,and hereby grant•Marion County,authorized agent of time <br /> Department of Environmental Quality,'permissiorrto enter onto the above idesoribedproperty for the sole purpose of this applicatipn. <br /> • <br /> 4:s4tY{ Na.•t.6- ie-FL.cr.asc. sCCt- 4'a- a-L74 37 0s. <br /> Applicants Name.-Please Print Legibly Applicants.Phone Number DEQ Lie.# (if applicable) <br /> 3 ct'l L L3SGt,.a •l--cr le Lc G-..,.o" a to 973 S's 1 <br /> Applicant's Mailing Address <br /> ,8-. . 7-.3 l-d 3 all Pt 3 0 <br /> Signature Date: CCH# (ifapplicable) <br /> Applicant is the 0 Owner Atithotizc d Rcpresentative ❑Authorization to Apply form Attached <br />