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• <br /> • • . . . • 1 -cbt. I c't5 <br /> Applicationfor Onsite• • . <br /> �!, C°L»�. pp tiOFor City Use Only: Date stamp: <br /> • Wastewater Treatment System city of <br /> y ®Date Received L: I V <br /> .-1111111 MARION COUNTY PUBLIC WORKS Received by . - J � <br /> _BUILDING INSPECTION DIVISION Zoning by AY 0 2 2019 <br /> • . 5155 Silverton Rd NE Fee <br /> . Sale&OR97305 MARION COUNTY • <br /> (503)588-5147 Fax(503)588-7948 Receipt# BUILDING INSPECTION <br /> wIIrw.co.marion.or.us/PW/Buildinglnspection Activity# <br /> - A:Property Owner Information •' <br /> • <br /> Name • Mailing Address City,State,and Zip •(Area Code)Phone# <br /> _ • <br /> . B.Legal Property Description . . <br /> • <br /> Legal Description • Tax Lot Acreage or Lot Size ' <br /> L. . <br /> Subdivision Name Lot Block <br /> - <br /> C��Y <br /> 'rop thy Address 4 City State Zip Code <br /> Directions to Property: - <br /> • <br /> • . C.Existing Facility/Proposed Facility/.Water Information - • - <br /> • <br /> Existing Facility: Proposed Facility: Water Supply: <br /> • <br /> ❑Sing e Family Residence ❑ sine Fly Residence - ['Public <br /> • <br /> Name <br /> Number of Bedrooms Number of Bedrooms g <br /> Private <br /> 111'Other ❑ Other . ` We S ' g,Shared •. <br /> . ' D.Type of Application' • <br /> 'EL3rte Evaluation ❑ Renewal Permit ❑Anthorizatioa Notice for: <br /> Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> • <br /> ❑ Repair Permit • ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Harr Rhip <br /> • ❑ Alteration Permit El Record Review ❑ Temporary Housing <br /> ❑ Major El Minor ❑ Other . ❑ Connecting to an.Eadsting 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 E vironmen Quality,permission to enter onto the above described property for the sole purpose of this•application. <br /> . .3 • . <br /> AAp licant's Name Ple 'l Prmt Legi 1 .Applicant's Phone Number • DE Lie.# if applicable)• � Q ( PP ) <br /> - Applicant's Mailing Address • - - <br /> • <br /> Signature Date: CCB# (if applicable) - . <br /> Applicant is the 0 Owner ❑Authorized Representative El Authorization to Apply form Attached <br />