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• <br /> • <br /> JApplication for Onsite <br /> II ��Ll,� For City Use Only: Date Stamp: - <br /> • Wastewater Treatment System City of ' <br /> Date Received � - <br /> 1 MA <br /> MARION COUNTY PUBLIC WORKS Received by <br /> _BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee <br /> • - ' . Sale&OR97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PW/Buildinglnspection Activity## • <br /> A.:Property Owner Information • <br /> . aLtVOILS ' <br /> P0353 ' 0..„2+vo►r_[ 7L2 . - <br /> Name Mailing Address Ci State,and Zi I e C <br /> • <br /> City, p � � one 63 <br /> - • • B.Legal Pro e Description <br /> Legal Description • Tax Lot Acreage or Lot Size ' <br /> 14a0 ,D �- 71M 20 bice41( . - <br /> Subdivision Name Lot Block ' <br /> 109Fove t/4-uj 7 ' De.i7740t9--- • qy7 . <br /> Property Address . V City • State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/.Water Information •- •. <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Sing e Family Residence / Single Family Residence Public <br /> !, 1 Name • <br /> Number of Bedrooms Number of Bedrooms ❑ Private ' <br /> ❑-Other ❑ Other • Well,Spring,Shared. •. <br /> • - D.Type of Application: • <br /> ❑ Site Evaluation ❑ Renewal Permit Authorizatioa Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement egl Replacing a Dwelling <br /> • <br /> El Repair Permit • ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> • El 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,permission to enter onto the above described property for the sole purpose of this•application. <br /> ____H-"0 e ft A.. ; ‘.... - -L----0a0.5 z-ii--q-74--54.M • . <br /> Applicant's Name—Please Print Legibly Applicant's P one Number DEQ Lic.# (if applicable) . <br /> --p <br /> ark SL13 0_12+voi( <br /> IIL D : 3Z. <br /> Applic.it's Mailing Address • • - ' <br /> . /0 04Ft—A IC 1/4,. • <br /> : afi 3 L/--/--iq <br /> Signa Ire Date: . . . CCB# (if applicable) - . <br /> Applicant is the caner 10 Authorized Representative 10 Authorization to Apply form Attached <br />