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<br /> Application for Onsite ,,,:,, _.,INSPECIticiii,
<br /> Wastewater Treatment System .i?:),1:Re%‘. '''':'''''''..jvcs, ',:! . 1 ''''!!':,',!:!:=?,1,,,:,:'!,1,1':,,j,t1i:',!tiii,,i,
<br /> IV ON COUNTY PUBLIC WORKS Receiv.ed F. by.-:.•. --. -'74,•,;,-.7..-••.'li,i61,'''-;, :',':',!•:: ,,?'--F:,.::'.'':111:!RO':01.
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<br /> ING INSPECTION DIVISION isaing.hy_,_'..--. -.:,:t• —•;', '..„..:771rji' ' :"
<br /> Ii1;i 1 1 5155 Silverton Rd NE Fee--- - .•.-7 -'-,7—';:!,Ng,,::::',..L,N ,,, ,;lk•,,,; :H.,:,:;,:it•-g.'!il .
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<br /> 1 .co.marion:or.us/PW/BuildingInspiel
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<br /> A.Property Owner Information - • , i .z,:;;-,7 i!!,,i,!;',.:..,:,,,*,.,,i'4-4;,E,:::•4:49:0:Zig
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<br /> 7'SIS-7-7 CIS 1:4"'''''. ...)- City,State,and Zip : , i7 --..,::N:::;;,,.:,:.,1,;,:;iia.:.:lat..
<br /> Mailing Address:
<br /> Name
<br /> B.Legal Property Description
<br /> ,.-;.-77-7!,-7-
<br /> Acreage;or.44# ir:-;:p,',,::: 4morm:1
<br /> Tax Lot Legal Description ' ''''::ii;'. :i:''-":,-':::::''•'-, •',„' ,IS).1!::,.trli
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<br /> Block " "::-- ',,,..•' c•:, •;,!:,-. "
<br /> Lot
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<br /> 2_,,g5 i.7 Ct!"1, ittAik-tSOtt St S. c.:4051-c-c3ir
<br /> state • Zip Co
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<br /> Prope i Add.•3;
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<br /> tions to Property: , . .., ,.,„,„,,,,„,,„ •
<br /> C.'Existing Facility/proposed Facility/Water Information iv,
<br /> acility:
<br /> BxiStii".F.aciiity: ,, '1%.1.,Zpp..
<br /> Pa".le Family Residence
<br /> 0/.51egle Family Residence Number of Bedrooms 0 Private . ,. ...„-Number of Bedrooms '• ' ::,'", ,', : nE:
<br /> Well,Spring,,B ';:• :' ],y!:::...
<br /> 0 Other
<br /> 0 Other • •
<br /> D.Type of Application
<br /> 0 Site Evaluation 0 Renewal Permit • [Authorization Notice for; • . ,,, .
<br /> 21,, ,ComnsFuc:on.o Permit D Existing System Evaluation O Permit Reinstatement ID Replacing a Dwelling
<br /> 0 Alteration Permit 0 Record Review t 0 Permit Transfer
<br /> 0 The Addition of One or More Bedr
<br /> 0 Personal Hardship
<br /> 0 Temporaiy Housing
<br /> 0 Connecting to an Existing System l
<br /> ci Major 0 Minor 0 Other
<br /> (E, i 1 (over 5-yrs old)
<br /> Other-Please Specify . 1
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<br /> If therequired fee and attachments are not included with this application,es it will be returned to you as incomplete.
<br /> Post the orange card at the entrance to the_property. gFla the test-.tio .
<br /> By my signature,I certify:that the information I have furnished is correct,.and hereby grant Marion County,authorized
<br /> Department of Environmental Quality,permission to enter onto th eabove,described property for the sole purpose of th
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<br /> Ai;-p521ficatit's Name-Pleas Pt Legibly ..4filiontitcs Phone Number''1. ':, ,':'..::, ,,,,-,:,,,!): ?Lie # (if applicable)
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<br /> Applicant's Mailing Address
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