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17-o3ads--?Ko <br /> Application for Onsite For <br /> CityC .,x�,y: Dale stamp; <br /> Wastewater Treatment System of <br /> allMARION <br /> Received <br /> MARION COUNTY PUBLIC WORKS Received by v r?((- it .1 ���2�l' <br /> BUILDING <br /> D <br /> BUILDING INSPECTION DIVISION Zoning by - <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 — AUG 23 2017 -74 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.ns/PW/Buidinelnspection Activity# MARION COUNTY <br /> l'UILDING INSPECTION <br /> _// A.Property Owner Information// p <br /> AA4y 57rkt104e- inceAbe,/ NEgpeagrd, oe ' 76 1 So3- 982-0/a3 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Prop�oDes Description <br /> 170 W S4 76B O r '/9 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name / Lot Block <br /> /F3a0 icheel" Rel Ni /74,L,Crivi ea_ 97037 <br /> Property Address v. II City ,� / / _ { State Zip Code <br /> Directions to Property: MAU C H e-vl 1-1-44,1 ACEI -1'P r�C/Let T /ted <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: 1 rlie / <br /> ingle Family Residence ❑ Single Family Residence <br /> a T❑Public Name e! t v <br /> �IS <br /> Number of Bedrooms Number of Bedrooms Private ft/(/e II <br /> 0 Other 0 Other Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> X Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> GWC Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ 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 furnished is correct,and hereby grant Marion County,authorized agent of the <br /> Department of Environmental Quality, <br /> permission to enter onto the above described property for the sole purpose of this application. <br /> 26kV✓y 0 lel der Sag- 6340- 2362 <br /> Applicant's Nai -Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> igD . e0' S7/ t-coif1. dr-c_e,4 O2 976ZZ <br /> Ape. is Mailing Addr- s <br /> - ,.teit/ ./ . Y-/S- zU /7 <br /> Or Signator- Date: CCB# (if applicable) <br /> Applicant is the 0 Owner Yf Authorized Representative jgrAuthorization to Apply form Attached <br />