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• <br /> • <br /> 1:313-C=UL1 lib <br /> Application for Onsite For City Uso Only: Date Stamp: <br /> - Wastewater Treatment System <br /> City pf <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING,INSPECTION.DIVISION Zoning by. <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt#: <br /> tx.,.ttr,siarieu or utt'ytLlrildrnaJns utirep. <br /> Activity# -._,- <br /> A.propertY Owner Information . : <br /> MHC HOPE VALLEY:LLC CIO ... . <br /> Fat CITY I IFFSSTYI F PROPFRTIFS 2 N RIVERSIDE PLZ STE 800 CHICAGO i IL 80606 - <br /> Name Mailing Address City,State,and Zip - (Area Code)Phone# <br /> B.Legal Property Description , <br /> ' 500 <br /> Legal Descriiptiou Tax Lot Acreage orLot:Size <br /> Subdivision Name Lot Block <br /> i 6372 ENCHANTED WAY SE TURNER _. 92 <br /> Qom . 973 <br /> Property�Address City State Zip Code <br /> Directions to Property.Start on Silverton Rd NE:Go 1.9 m,then turn left onto Hawthorne-Ave NE,Go 1.3 mt,then turn left onto Market St NE; <br /> Do 600 ft.then turn right for 1-5 S:Go 717 mi.then take exit 248 onto Delaney Rd.Go 800 ft.°then tun letfonto Delaney Rd SE:GO 500 ft,then <br /> turn right onto Enchanted Way SE;destination Is on the left. <br /> C Existing Facility!Proposed Facility/Water Information , , <br /> Existing Facility: Proposed Facility:, Water Supply: <br /> ['single Family Residence 0 Single Family Residence ['Public <br /> Number of Bedrooms Number of Bedrooms El Private, Well`_ <br /> Wad 164 Manufactured Homes ® Other Add treatment and DF far`5,94i) <br /> ® gpd Well,Spring,Shared <br /> D:Type,ofApplicatioa;, , <br /> 2/ Site Evaluation 0 Renewal Permit ❑Authorization Notice foil <br /> O Construction Permit 0 Permit Reinstatement 0 Replacing a Dwelling <br /> ❑ Repair Permit 0 Permit Transfer ❑ The Addition of One or More Bedrooms: <br /> ❑ Major 0 Minor 0 Existing System"Evaluation ElPersonal Hardship <br /> ❑ Alteration Permit 0 Record Review 0 Tea porary;Housing <br /> ❑ Major. 0 Minor 0 Other ❑ Connecting to an Existing System Neves:in Use <br /> (over 5-y6 old) <br /> • 0 Other-PleaseSpecify , <br /> lithe required fee and attachments are not included with this application;it will be returned to you as incomplete. <br /> Post the orange cud at the entrance to the property..Plag 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 /> et Pt(-DIVA K{kwamsp ,S 6 So sILI caog S <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ.LIc.# (if applicable) <br /> 73tn N i.6w` $r 300 <br /> Phae-441)C. N't $ Sd Lo • <br /> Applicant's Mailing Address _ <br /> irar.‘,..— k 4 L//, 312-.o 2 ' <br /> Signature Date: CCB# (if applicable) <br /> Applicant isthe❑Owner al Authorized lteprnsentative 0 Authorization to Apply form Attached <br />