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EXPIRED A-,-,-0, <br /> - 0,7-15`4 p0\--,-Ol <br /> ,, wy, Application for Onsite For City Use Only: -� i <br /> C L LI <br /> NE City of / <br /> .. _ Wastewater Treatment SystemIIIIIII <br /> ED <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by JU `3 Q 1021 <br /> BUILDING INSPECTION DIVISION Zoning by MARI <br /> 5155 Silverton Rd NE BUILDIN N COUNT' <br /> Fee INSPECTION <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> vs vs ww.co.marion.or.us/PW/Buildinelnx_pection Activity# <br /> A. Property Owner Information <br /> ►4\ ef-\ L'-\\ I-� PG Box LOCI LYt;r15 CPS (R13P- t SC) -179 - Lj <br /> Name Mailing Address Cit}t, State,did Zip (Area Code) Phone# <br /> B. Legal Propetv 4escriptiion <br /> 0q31 H 0 I 0 Ac-ems C%.12 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <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 b Single Family Residence ❑Public <br /> NoAL, , 2 Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private tAle.11 <br /> ❑ Other ❑ Other Well, Spring,Shared <br /> D.Type of Applicati rt <br /> ❑ Site Evaluation ❑ Renewal Permit ►iI Aut. i rization Notice for: r' . <br /> Construction Permit ❑ Permit Reinstatement Replacing a Dwelling <br /> C:3 <br /> Re air Permt ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ' ._MajorMinor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other ❑ Connecting to an Existing System Never in Use cp., <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 /> Cl city _In -e 1 l C_ E()S -- (1 3 - .;z25 t 36) 1 q 0 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic. # (if applicable) <br /> IS -3 . e n e 1:.Dra�1 P l cvf, I J-k r�;{A 0 t _ cvi`1 3 <br /> Applicant's Mailing Ad s C <br /> J ' <br /> 4 / <br /> 1-et,-/ 1,J _ r gin3jai Q72C cr5 HI <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner fa-Authorized Representative ❑Authorization to Apply form Attached <br />