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• <br /> • . . <br /> . . 1.8tbcAli <br /> • <br /> . ' . <br /> . _ . <br /> Application for On site . For City Use Only: Date Stamp: , . <br /> • Wastewater Treatment System city of . <br /> Date Received • D 5 C E-V I, <br /> MARION COUNTY PUBLIC WORKS • Received by -� <br /> _BUILDINNE <br /> G INS ECTton ONRDIDVISION Zoning by NOV o 7 201 ,.� <br /> Fee. <br /> _ SaletOR97305 � � COUNTY <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> w��w.co.marion.or.us/PWBuildingInspection Activity# <br /> BUILDING INSPECTION <br /> • <br /> A:PiopertyyOwner Information • <br /> Urn. Srn�i ?.d g 3`).°N S-c . ? `e / 7/37 503—.aoci _yGys7 <br /> Name Mailing Address City,State,and Zip .(Area Code)Phone# <br /> /„� 36 ld U . B.Legal Property Description • _ <br /> Legal Description Tax Lot Acreage or Lot Size. • <br /> Subdivision Name Lot Block <br /> acti v\Q11 T\ . -5 <br /> Property Address V City State Zip Code <br /> Directions to Property: - <br /> C.Existing Facility/Proposed Facility/.Water Information . • <br /> • <br /> Existing Facility: Proposed Facility: Water Supply: <br /> • <br /> ['Single Family Residence Single Family Residence ❑Public <br /> - <br /> '3Name • <br /> NnmberofBedrooms Number of Bedrooms Private 7 <br /> ❑ Other ❑ Other • Well Spring,Shared <br /> • • D.Type of Application' • <br /> ❑ Site Evaluation ❑ Renewal Permit in r thorizatioa-Notice for: <br /> ❑ Construction Permit ❑ P emit Reinstatement )Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> El Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> • Alteration Permit ❑ Record Review El Temporary Housing <br /> Maj or ❑ Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> . (over 5-yrs old) <br /> ❑ 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 /> • 3q.)- 10?3 .. 33© / 3 <br /> Applicant's Name—Please Print Legibly •Applicant's Phone Number DEQ Lic.# (if applicable) <br /> P c). . teo y 9-2 i-7 ) ieve,, f6s 0 g . <br /> -7-7 7„5--- • <br /> .. <br /> • Applicant's .Q ddress <br /> • • •4( A • ' // 7. ' / S/ - <br /> Signature Date:• CCB# (if applicable)• ' <br /> • <br /> Applicant is the 0Owner Authorized Representative ❑Authorization to Apply form Attached <br />