|
. -X---J5-
<br /> 2-3-oo Scno—El/A-L._
<br /> .
<br /> . .
<br /> Application for Orisite. .
<br /> For city 1.1se.Ooly.:. !:, Date Stamp:., . ,
<br /> Wastewater Treatment.System . :c'tY(4.-
<br /> . .
<br /> - . .Date Received
<br /> . ' ': . . . •,.,,,, .., . • , '. .. .. .
<br /> MN
<br /> MARION.COUNTY-PUBLICWORKS" ' Received by
<br /> . ' • 1
<br /> . . . . . . . .
<br /> ougiaNGINSPEcTIQN DIVISION . . Zoning by, - • ! •I , ! 1
<br /> , .
<br /> .• •' - ,, ' ' 1 5155,Silvirton Rd.NE -, •' !
<br /> ... • Pee .
<br /> •SOlem.0.97305 - -- .
<br /> (503)$88-5147.. Fair(503)-588,7948 Receipt . 1
<br /> wvilw.cillitririOnAlt.irs/PW/Btrildinghispectioa- ' Activity# •! :
<br /> . . .
<br /> . .
<br /> . . ..
<br /> . . .. . .
<br /> .i1,-,i;,„,-.7.-,'.7.7r,..:,..:.,,,..—..,,_ ,:...1.. ,r,,,-.',..:,--7- 47, to. r,:;p7:77.:27.,;tittr. ,Tr:,,,,,t.7._ ,.-,*,:77•i'..7-4,7,,,,W:',1-;,,,,r4,,r-..7,,,z71,-.7.,-.7,,Fi'*',5y,,,,,n,71,43,kf,,r,.T.,,,,,,,-;try;1.-c',":1;;-,-'..-01.),,-----,.ti .,,,,,,,,....--,77enrg,,--E, ... ,,,,,,,, i
<br /> iirci,Vitifga=i'i:iiiiiififfiPicktiiiViy6V441:44VV42,Z1-14.0,1.4i,'Mptrty„'<WOVIttonn:41104.;',M,..,0,;,,. .,,,Vu,,,'•.,,...,5,,,,, -:-T,-Wp,,zwri,j:',,,,,,,,,,,..to,10/2,44Mff,,,,,m4, ,
<br /> ,Trust,dated August 22;2015- '-'-' '-'-''''''1"----- '• '*."'''''•* '--. • 7 '''::'''''"''''!''''''",7,-^' .'-'1',^:'`.4. '''''''''
<br /> Lisa J Barnes as Trustee of the Tristen Barnes Irrevocable
<br /> Investment Trust.dated December 15,2015 . - • P.O Box 4594... ... . -Salpm, OR 97302 . . 503-519-5046
<br /> ... . . „.
<br /> Naitie..... - . -. .-.:.! " . ._ :.•Mailing Addrist ' . .. !:.!: ,City,-statd,'imdzip :-:- . :. .•(Area COdephend#
<br /> Township 9S,Range 1W,Section 48,Tax Lot 1700,Section 5 TaxLot i0O,airc11.63Uhtji 7
<br /> 'I Tax Lot 1700&400 '''''' '"---''''''' 7"..`",":'-':-.'14"'IR"--'''"e'"-T7.77-',.... `-'4741I.I.1.4.,,,a41 -1-A•• 1 ,
<br /> •
<br /> egg4 Description: ! ! - ! ! ' --.' " ' Tax Lot ! ! -' ' Acreage,orLot Size1 -
<br /> I
<br /> . .. !
<br /> '- • • . . . -. ... . . .• , .„ .
<br /> Subdivision Name '' - ! !'' ' Lot ! ' ' •-!," Block
<br /> ,•
<br /> 1 --05--!goif Club Rd . Aumsville • OR
<br /> 97325
<br /> Property Address :-. . .: City -— State Zipieode--.
<br /> • i .
<br /> Dite.etiiiiis tO-Pl'Opterty:- 6?‹76 ig.,-,•!--- ( Goi-r cl el?-. /2/52-fit . .s as:7 .---.5.-Q6 b „pi /Le.(-..zi -10 .6<ce.:
<br /> ' ..' .(Y, - t.. ,
<br /> , ...
<br /> , . ..., . . . -
<br /> - • " • ' : ' ' ... . . . !
<br /> -e:11+,:f.411 -",, iiii.Siaill141:041,4,,ki,,ilIfe.-11:4'ilitItYroP,SO4-,E1I-Mloit,LW-1,04:VO•t44,1,1211Iig?t,144talinalikagliflifIai 1-. 'i
<br /> ,Etisting-fociRty: PinpaseilltiCility: • Water Supply:.
<br /> 1:7jiogle Family Residence )ErSingle Fatally Residence ,,OPublie - . .•
<br /> ! - g Name. !
<br /> . . „,.
<br /> •:Nurriber of Bethnal:11.S •Number of Bedrooms (NIZS4)rivate 4ilIKED
<br /> 0 other: , : . , . . . • C3 Other .,. . - ' • .1/VeLl,Spr,mg,Shored
<br /> lifill,,,,•,!' ,:•.! ! : :,!,• - -:-?_.•.!! ',7:103FriM!,_,..',,,t,,,fl-7,----''','7..- '!••.'-IIII I.2,4 -7-rr fi • riiiiirin.7 _ . —- njailitill I
<br /> Site Evaluation . 0 Renewal Permit ! !'0Antlint*.tion..NotiCe for !!
<br /> .,, ., . ... .
<br /> 0 Construction Permit -0.Permit ReinStaternent !.
<br /> ... . .- 0-Replacing'o.Dvielling. : .•• ' ,
<br /> 0..Repair Permit !Ej Permit Transfer 0 The.Additietinf One bt More Bedrooms
<br /> 0. Major ""O.Minor i[3, Existing System Evaluation .0 Personal fltiOallip . -•' ... . ' I'. ,. - . . . .
<br /> 0 AlietatiOnPenialt; (3,,ReCotd Review- . ' :El Temporary Housing 0 Major E Miner D Other 0 Connecting to an Existing System Never,n 3s.e.
<br /> , . . ' .,,, ••(over 5-yrao14, • , . .
<br /> 0 Other• -PleaseSpeCity• ! I
<br /> .flthO:requiiedfee:04'attachment:ii.i,te,not included*00;0:00401On,it will be.retyrned.co you.0.ineaiiirileto. .. ,
<br /> .' 'Peathe.orange cortLet the entrance to thesiroperkv; Flag the test boles. . .,:: •
<br /> By my.signature,I certify that• the information I have furnished is correct,and hereby!giant*,ation'County,Inthotized agent.of tbe. 1:
<br /> . ... ...
<br /> .: •:... ,
<br /> Department of Environmental Quality,permission to enter onto the above deStribed-property for-the:sole purpose of this tippliCOtiOn..
<br /> Michael R Barnes,Trustee&Lisa J Barnes,Trustee' , 503-510-5046 . •.•. . • . .,. . . _...
<br /> Applicanes191inie• please:Print.1.4gibly- Applicant'i Phone-M*36f • -DEQ:LiC.# :(if applicable) . '
<br /> .
<br /> .,
<br /> , ! ,
<br /> .!.
<br /> P 0 Box 4594,Salem,OR 97302 • 1
<br /> Applicant's Mailing Adgress. ' • •
<br /> .- '
<br /> • .
<br /> •
<br /> .Date. CCB#.(if applicable). ' • ' ,
<br /> Applicant is the. Owner0Anthorited.Represen4tiVe 1:1' '.Authorizationto-Apply:form:Attached i'•
<br /> FAFORKS\Strin- S-Oi9:24$iTt APPL 101..x 2,022.bock'Re*1/15,•.3/18;6i24
<br /> C
<br /> i•
<br /> •
<br /> ..:.....!
<br />
|