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Application for Onsite For CityUxeOnly: mmStamp: <br /> Wastewater Treatment System City of p Ip�/p <br /> Date Received i t' ECILI V I0 <br /> Ella MARION COUNTY PUBLIC WORKS Received by ,_ 'r{I <br /> BUILDING INSPECTION DIVISION Zoning by _ - NOV <br /> JJ <br /> 5155 Silverton Rd NE -. NOV 1 5 2017 <br /> Fee <br /> Salem OR 97305 <br /> (503)588-5 47 Fax(503 58 g-7948 Receipt# - nH`11UN COUNTY <br /> www.co.marson.or.us/PW/BuiidioglnspectionActivity# BUILDING INSPECTION N <br /> ' A.Property Owner Information <br /> ✓eN(1/ Wluowxw S33NSPr-iYA- tip Ie, >AewiG2 2?nl, 5'a3-es-/-So23 <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 /> 14k' S-747it y) Sr rye ae- <br /> Property Address .�// � City ,,// � State Zip Code <br /> Directions[R Property: yf2oQn �4-C4n/ to I/771'/J e7 s7 J .Syyirc- a2 t� r,._.- <br /> 4,742>z <br /> , <br /> ��2d/ / "14,,,,-- <br /> C. <br /> iliirC.Existing Facility/Proposed Facility/Water Inf9Rnation <br /> Existing Facility: Proposed Facility: Water Supply: <br /> [Single Family Residence 0 Single Family Residence ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms { Private a l-L- <br /> ❑ Other 0 Other _ °y\ __fitWell,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> O Construction Permit ❑ Permit Reinstatement 9 Replacing a Dwelling <br /> ] Repair Permit 17I Permit Transfer ID The Addition of One or More Bedrooms <br /> 1:1 <br /> 9 Major 0 Minor ❑ Existing System Evaluation 9 Personal Hardship <br /> 9 Alteration Permit 9 Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor 9 Other ❑ 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 /> _ <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 /> O Jkv (A/f7 t/M7AJM/& 2'3-Q32 -1/1fle 3g 531 <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lie.It (if applicable) <br /> /3 _ /7 TV f /Ze'Z eA2 497307 <br /> Applicant's Mailing Address <br /> D <br /> % - V i/lir/-� 26566,/ <br /> Date: CCB# (if applicable) <br /> Applicant is the❑Owner Authorized Representative IILT Authorization to Apply form Attached <br />