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do-cb625q <br /> Application for()mite For oity7 the oily: ar#Otatnar <br /> Cityof <br /> * ------- .7.- Wastewater System. <br /> Date Received <br /> csop 2O2 cN3 T y <br /> u s I- <br /> MARION COUNTY PUBUCWORKS- . Received by .. ECEgyE IN <br /> BIALIAN011410RiTIONMVistort i. Zoning by- <br /> 48.1'.giiiv,OttOit lid:NE .. <br /> OCTNo <br /> tale._1104 9710f. <br /> (503158S-5141 Fax0011.$084948, Receipt# <br /> W**emnideintor•fik108vintilliiilidrintietition Attivit7#, BUILDING <br /> D MARIONI <br /> TION <br /> A.Property. OwnerTtiThrmatilon. <br /> , <br /> . - -- ' <br /> , ge geek-da)e// zif6 9.6z4A0 /ekto Sa&titl .6v- 71.?-‘7 5705- - <br /> Name *Mailing Address City,State,and:Zip (Area Code)Phohc# <br /> liL,T.,egalFmpertyttetiptitia <br /> Legit De*tp-don r4x 1.4t Acrcage-or Lot Sim <br /> Subdivision Name Lot BlOck, <br /> . ,, , <br /> 330'. \latet ti. .-e 0--1—` D(9(--g-6-);4- A,r <br /> , <br /> Ptopertimdoe.ss. City State Zip:Cade <br /> Directions to•krOlSitY1 <br /> . . <br /> C.Existing Facility/Proposed FaCility/Watenttformation <br /> •Eliisting#atility: Prpirsed Facility*: Water Sop*: <br /> ainglePainilyttesitienee ipingleFamilYgesirlence 1,711131te 796(6 l\-- <br /> S . Nome <br /> NionbernfSedrootria NumberofSfairoonis El'Private <br /> Er pi*. _ ra.Other. <br /> Well.Spring,Shared <br /> D.Type of Application <br /> tirCi0 Site Evaluation CI ROCCiiral*Ferrnit DAut110tinttiort Notice for <br /> ntstructionTerniit: 0 Permit Reinstatement El:RePincl#4,AD%velling <br /> Repair Permit 0‘FerinitTratisfer 0'ThoAtiOitt000r One.or.Mule:Redrotikas <br /> 0 1,103r 0 Mint* 0 Exiating3SYstettrEvaluation 0 EON*Hardship <br /> CI Alteration Pcmlit El Record Role* CI Temporary Housing <br /> 0 Major 0 Minor 0'Other ct: Connecting to an Existing-System Never in Use <br /> (oiler:51ms-old) <br /> 0 Other-FleaseSpee* <br /> rthereotirettfeedm4 dAtteinzentgaro not ittelitded*Orilla application it will be returned taxi*as inthmplete. <br /> Polt,the'orange.cardat the entrance.to thopropetty, Flag the <br /> BY.413raitaahtt_e_ .I Oattit that the htfatitlatibal'hawfinnialiedia correct,and berehygiant*MatiOnCounty,,anthorited.ngent of the <br /> Department of Envirotithentaf quality;17etniittion tO eilter onto the iti)oVodescrileil:PropertYfofthe-sole purpose of dila application. <br /> Dr evo Cot v el' 6C,-- '4/9 g•7-.?-4,: . s,%--.-'3--.-(-i - <br /> AppliOtralslante=PleasePtint,Legibly Applicant'iPhone'Number DEQ Lie.#(if applicable), <br /> lc..e17 .: le- 10e, 9767 <br /> Applicant's*Ring Address <br /> act...,.._ ?. 2(-). z0z3 <br /> / I 6 &5-6 <br /> / / <br /> Signature4' Dote 'CCB#(itapplicable) <br /> ApPlieant is the Et Owner t:AnthariZed Representathte 0 Autfiorikution.to Apply ft/no-Attached <br /> -" <br />