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<br /> AppliA l eation for ans to -
<br /> cation. .- Y . For City tine Only: Date Stsmp:
<br /> Wastewater Treatment System. City of
<br /> Date Received r-. 'If-r rr P`�� _ 1
<br /> MARION COUNTY PUBLIC WORKS Received-by cr:) !
<br /> : BUILDING INSPECTION DIVISION Zoning by JUL 2 202
<br /> S155 Silverton Rd;NE Fee
<br /> SiilentOR 973'05 •
<br /> (so3)sas-Sale . Ezax(so3)s8s-?9ag Receipt# M\RI ON COU N '
<br /> wK w.co.miiri.. . , n... ,. uiliiin�><nsaection'
<br /> Activity# . SUILPI NG INSPECT 10E
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<br /> -. ... ,. ..,M..r��� ,.�,w, ��s„ ,.� w x�.r � `��`�-A.��iM����d'�IIE'ft 1�Or3[1at1o1'1^ .u.m �.v...,..,,. .. a ,., -, ...,,, •, .., .. ..
<br /> Mailin Address City State,and Zip Ph(Area Code)P ne�
<br /> , _.. -1 ..r £:,.egal.Pa oiler -Descnp#on" .,
<br /> Legal Description Tax Lot
<br /> Acreage or Lot Size:
<br /> -
<br /> Subdivi 12 n Namo Lot Block
<br /> :.1.:'. ' . '9i6ZHEitit'''' ;it.;i‘'kelit. .'qaj tb ' Jio'^d .
<br /> Property AddreSS city t3 State Zip Ce
<br /> Directions to Property;
<br /> •
<br /> •?. "`..' s 4 .n• ,-- w, E ng F`actlt ijti-csposed�F'aciht5>l �r Ir,msnaticux T : „
<br /> E�nsttng;Facility Proposed Facihl ater,Supply:
<br /> P!Single F I kesiden•ce ❑ Single Fa•msl}'ke"silence :Public
<br /> Numbero ' edrooms Number of Bedrooms
<br /> Pr ate w6LL
<br /> 0 5' _ ❑ Other T i` .. [ y� Well,Sprang,Shared
<br /> , .c, �. ',4. 7t'a f{Y •- H 4__ 3 tX .)::l-p�. 7;: 1: i ria oi? "� .+ .t:�°i '�" Y' T,, '.W. .'"er,+,� , y, 3- z's"axeC
<br /> s x, . ^a^..^. x yak' .r -4q. :„: ,-,xz, ,...3 z.$•f,;z "xz ga,-' A:= 4S t "aK x, Fs- '
<br /> sif..Evaluation.
<br /> ❑ Renewal•Permit tha iza❑�1u r bon•Notice for:'
<br /> Reonstruction Permit.' ❑ Permit Reinstatement Q Replacing a Dwelling
<br /> pair Permit .
<br /> p ," ❑ Perrnrt Tramfer ❑ The Addition of One.dt=More Bedrooms-
<br /> ii1.Nl.alor ❑ Minor <❑ Existing System.Evaluation: ❑.:Personal Hardship
<br /> Alteration Pe•mtt• ❑ iRecoied.k6iriew -
<br /> ❑'Temporary Housing '"
<br /> Major.: '0 Minor ❑ Other ❑'Connecting to an Existif g System Never in Use
<br /> (over 5-yrs old),
<br /> - ❑ Other-Please Specify,
<br /> I.
<br /> If the'reguared fee-and attachen ts m 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 cer"til3"that the information I ha,e.furnished is correct,,a nd=hereby.grant Marion County,::authorized agent of the
<br /> Department of Environmental Qualtty,.perraission to enter onto the above described property for.the sole purpose of this application. -
<br /> C: S:©5 - ; ----nag • 6S
<br /> App h. "
<br /> It 's Name—.Please Print Zegtblp Apphcant's Phone I�Iu•mber D)?Q:Lic.t# (if.applicable) .
<br /> , . .,,..
<br /> `. Applicant's Mailing Addres
<br /> Signs Date: Zffapphca )CCB
<br /> Applicant is the.❑Owner Authorized Representative Authorization to AppI form.At..-
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