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<br /> Application for Onsite For City Use Only: nate Stamp:
<br /> Wastewater Treatment System City of I -D -
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<br /> - Date Received ,
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<br /> MARION COUNTY PUBLIC WORKS Received by in_ JUL 10 2023 ,)BUILDING INSPECTION DIVISION Zoning by
<br /> 5155Silverion-Rd.NE Fee ,
<br /> Stileui OR 9730S hAAE-tION COUNTY
<br /> (503)588-5147 Fax(503),588-7948 Reedipt# aUILDII\IG INSPECTION
<br /> #t Activity www.co.marion.or.usirW/BiiildineInsoection Ac
<br /> A.::Pioperty0ivier Information
<br /> ktse,,ANNO„n— $5. '1 , ' ' , 6 .f,-, • , • „ ... • 43 • 2 Karen ( I pt/ficioton cil- s 5 levn oiz. ct--4'3%-+ 501 it 2 66
<br /> Name Mailing Address City,State,and (Area Phone#
<br /> 2 wi„.:.-„,--- --.‘a ...„:„:-13..IegaiPt)V)Pes01101V., „; ,,,t1,:, • - ,,,,,•-•„:„•,-..:,.
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<br /> 1. Legal Description Tax Lot Acreage or Lot Size:
<br /> 1Aioca5 3
<br /> ttbdiviaiotiNante Lof Block
<br /> 8 5i I PcS6ctekAin CA-, 56 CO/211-4^A .(le_
<br /> '.: PruPer.ty Addrest City State Zip: Code
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<br /> Directions:to Property
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<br /> C.Existing Facility/PrOpOsedfaciEtic*i*Iiiforritifitin ; -":". :-'-',.:•::::::,-;:,,i - ,:(''' :•-
<br /> ExistingEneility: Proposed Facility: Water Supply:
<br /> ,giiigle Family Residence 0 Single Family Residence 0Public ,
<br /> qName
<br /> Number Of Bedrooms Number of Bedrooms 0 Private
<br /> 0 Other 0 Other Well,Spring,Shared
<br /> iji:TYpe;OrAlirdic409!W''!`:::',/:?
<br /> 0 Site Evaluation 0 Renewal Permit 0 AritheritatiOn.Notice for
<br /> .,..,. 0 Construction Permit 0 Permit Reinstatement 0 ItFOliOntaPYielling ,
<br /> ,1 . p.97:*p*Pqmait- . 0 Permit Transfer 0 The of Addition One or More Bedrooms
<br /> :j,Major " ' . " - 1 '. XMinor 0 Existing System Evaluation 0 Personal Hardship
<br /> . . , ,. . ,
<br /> 1 0 Alteration Permit 0 Record:Review 0 Temporary Housing
<br /> 0 Major 0 Moor '0 Other El Connectinglo ari Existing•System Never in the
<br /> (over 5-yrs old)
<br /> , • 0,Other-Please:Stiecify
<br /> (Ziti)Icit ihtn *pro,p 1;50t. • V :4t 7._ .
<br /> If the iiquirezifei.and:otOknierits are not included with 1/us applkation,it be as incomplete
<br /> !-- . PoStilie.orangecird it theentrance.to.the property. #lagthe test holes.
<br /> 43i'my signature,I certify that the information I have banished is correct,and hereby grant Maricniconnty',authorized agent of the
<br /> Department of Environmental Quality,permission to enter onto the above described property for the sale purpose ofthis application.
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<br /> Applicant's Name:-Please Print Legibly Applicant's Phone Number -DEQ Lit cif applicable)
<br /> IP.0 ` t 'o piok106.4.1 OrGluei.
<br /> ,i' Appli-.1,Tt Nail ing A f.'
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<br /> 7+71 10 1 J3 2,3 I 55$ T. f
<br /> ,i, l '. . •A,,Si Date- -- Date: . CCB# (if applicable)
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<br /> Applicant is the 0 Owner ' Authorized Representative 0 Authorization to Apply form Attached
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