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11 -CC\5171-\ <br /> Application for Onsite For Gry use Only: Hare stump: <br /> Wastewater Treatment System City of M D <br /> - Date Received G� '^_ _E,INE V/ <br /> MARION COUNTY PUBLIC WORKS Received by 1' q 1l <br /> BUILDING INSPECTION DIVISION Zoning by iii U"�.2017 <br /> 5155 Silverton Rd NE Fee MARION COUNTY <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# Bt IILDING NSPECTION <br /> www.co.marion.or.us/PWBuildingInspection Activity ft <br /> A.Property Owner Information <br /> Br()CP WOW 1010 tfa,ties Strut AF Angel ,OR 91302 503.510 .6)L224.0 <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> 4S, tU , e Nan), &IAon <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> I 43 1I "ranch Proarlt kr) Al St . &ai4 02- Q2 97137 <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 0 Single Family Residence ['Public <br /> Name <br /> Number f Bedrooms Number of Bedrooms 0 Private <br /> ❑ Other 0 Other Well, `.Bring, Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> AConstruction Permit 0 Permit Reinstatement 0 Replacing a Dwelling <br /> Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation 0 Personal Hardship <br /> 0 Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other ❑ Connecting to an Existing 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 famished 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 /> $nice. WoK-F 503.51o• lWo2te <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> logo Hces Sfre t , i.A+ Angel . Ce. 9731oa- <br /> Applicant's Mailing Address <br /> --- -/ LX/L LI 1-/ <br /> Se t Date: CCB# (if applicable) <br /> Applicant is the Owner ❑Authorized Representative 0 Authorization to Apply form Attached <br />