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y-0-0 qZ6ci 110111 <br /> Pieitirr <br /> ., ,;,; ,,_ Application for Onsite For City Use only: Date stamp: <br /> no <br /> =j Wastewater Treatment System City of <br /> Date Received Q R E V E. n <br /> MARION COUNTY PUBLIC WORKS Received by J <br /> BUILDING INSPECTION DIVISION Zoning by MA" 31 2024 l <br /> 5155Rd NE <br /> Salemv erton R97 05 Fee MARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 Receipty Activi # B U I LD I N(i INSPECTION! <br /> www.co.marlon.orms/PW/Buildlnalnsueetion <br /> A.Property Owner Information <br /> cat- uhictr 1i-gt6 L;b SE �tf.cersan , off SO3- 510- 8808 <br /> Name Mailing Address L i , City,State,and Zip (Area Code)Phone# <br /> o4 Z-W 320000 8 co B.Legal Pro2erty Description S. 3 6 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> I'1GU Libby In SE <br /> Subdivision Name I Lot Block <br /> -Seffusei pR Q1352 <br /> Property Address Ci r State Zip Code <br /> Directions to Property: '{PP Rox. 1/1 yv i N 0 R N t it ,(sm-Mtir thi OP SE <br /> C.Existing Facility/Proposed Facility/Water Information . <br /> , <br /> Existing Facility: . , ,sed Faculty: Water Supply: <br /> &Single Family Residence Li Single Family Residence ❑Public <br /> HMO b t 111 rt,yn0{�;eJ 3 Name <br /> Number of B�oms Number of Bedrooms Fr Private <br /> ❑ Other 0 Other eh Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> Q,Construcdon Permit 0 Permit Reinstatement 0 Replacing a Dwelling <br /> ? g3 RApir Permit ❑ Permit Transfer 0 The.Addition of One or More Bedrooms <br /> • Major 0 Minor 0 Existing System Evaluation 0 Personal Hardship <br /> []Al on Permit 0 Record Review 0 Temporary Housing <br /> Hil Major ❑ Minor ❑ Other 0 Connecting to an Existing System Never in Use <br /> WOTE: sAouSt c411;41 off 4:11 (over 5-yrs old) <br /> 0 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,1 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 /> Te95 .gi'Se vi vfri qg So3-731-2I/o/ 3‘323 <br /> Applicant's Name—Please Print Legii yy Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 36901'o ,,i;r I,lJAy SE 5ft 1, OR f?7 17 <br /> Applicant's ailing Address <br /> / 0 5 lb/V _CO/7/ <br /> s. Date: CCB# (if applicable) <br /> Applicant is the 0 Owner authorized Representative [utharixation to Apply form Attached <br />