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Application for Onsite For City Use Only: nate Stamp: <br /> it Wastewater Treatment System C"7 ofMilli p p <br /> Date Received D L l`-o Ig _ \'!/ E <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by , -9 <br /> 5155 Silverton Rd NE Fee NOV 15 2017 <br /> Salem OR 97305 Receipt 14 tvlAfYiL N t..:. UNtY <br /> (503)588-5147 Fax(503)588-7948 Activity# BUILDINGINSPECTION <br /> www.co.marion.onus/PWBuildinglnspection <br /> A.Property Owner Information. <br /> /6-7dw6 517f422g 4tr., , ale 973/7 3t?-932-V77Co <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 571- (a3gan kW Nd Gelid 6332 971/1 <br /> Property Address ..// City ((� State Zip Code <br /> Directions to Property: *//WI '!//7L* c. '2 D (4-1170 1,44 t vL ('7g ,470,0,62C <br /> v00 pr <br /> C.Existing Facility/Proposed Facility/Water Informafion <br /> Existing Facility: - Proposed Facility: Water Supply: <br /> Single Family Residence 0 Single Family Residence ❑Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms 0 Private Wt2L- <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D.Type of Application <br /> O Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> O Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer 0 The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> lcAlteration Permit ❑ Record Review ❑ Temporary Housing <br /> ` ❑ Major X Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> (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,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 /> _Je-7p1c✓�r/ i3-932-V77c. <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> c7r 43&7 4rNr ,S,11-644roe 97 w7 <br /> Applicant's Mailing Address <br /> -‘&77(1 7//r-1li- <br /> i Date: CCB# (if applicable) <br /> Applicant is the b41 Owner 0 Authorized Representative ❑Authorization to Apply form Attached <br />