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scorj - lrk - bo bct3Z -€Jc <br /> Application for Onsite For City Use Only: Date Stamp: <br /> Wastewater Treatment System City Of <br /> all Date Received <br /> Received r�� /, <br /> MARION COUNTY PUBLIC WORKS i ��' t <br /> -BUILDING INSPECTION DIVISION Zoning by �� - II I) <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 Receipt# SEP 082017 <br /> (503)588-5147 Fax(503)588-7948 Antivlty# <br /> www.co.marion.opus/PWBoildinelnsoection MAHION! GCiu'J i Y <br /> BUILDING INSPECtION <br /> A.Property Owner Information <br /> 0.hrt4 P er4eln ?o box a t * Pa, CJ2c7/3 503-209-c' <br /> Name Mailing Address City,State,and ZIG (Area Code)Phone# <br /> B.Legal Property Description <br /> P.P. tot\-oitc QarLcL. -2_ o` tuA2 '03CONo0 "5S , Sok. <br /> Legal Description Tax Lot Acreage or Lot Size <br /> • l / 7- <br /> Subdivision <br /> Subdivision Name Lot Block <br /> `-\`305 \ i..#-AS\ Ogles ON c. \\It 5\ - QCk O(R,„ Q"t-\ -k- <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 X Single Family Residence OPublic <br /> Li Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> ❑ Other ❑ Other Well,Spring.Shared <br /> ,.,�( 11 Type of Application <br /> W Site Evaluation ❑ Renewal Permit nAuthorization Notice for: <br /> ❑ Construction Permit 9 Permit Reinstatement ❑ Replacing a Dwelling <br /> 9 Repair Permit 9 Permit Transfer 9 The Addition of One or More Bedrooms <br /> ❑ Major 9 Minor 9 Existing System Evaluation ❑ Personal Hardship <br /> 9 Alteration Permit 9 Record Review 9 Temporary Housing <br /> 9 Major 9 Minor ❑ Other 9 Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 9 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 /> hr/5 1')erii-eo 5-63-:20c-5751 <br /> 1 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lie.# (if applicable) <br /> Ro 'DCk 1 S. P (2)-P_ 7137 <br /> Applicant's Mailing Address (`�, <br /> Signature / ' "� / /V/7 <br /> Date: " CCB# (if applicable) <br /> Applicant is the YlM jswner 9 Authorized Representative 9 Authorization to Apply form Attached <br />