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ALA-Ebt-%IsA
<br /> Application tor Onsite
<br /> , '
<br /> .for-City'nscoldit-, . ,
<br /> zat**Pitg.
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<br /> . ----.'"'": -;.'.--; •7 .' Wastewater Treatment System eitrof. -- :rtik,itgtoived.
<br /> RECEIVED
<br /> MIN
<br /> .ivtARIONCOUNT*ATBLICVORKS Iteteired..hy'
<br /> BUILDING INSPECTION DIVISION Zoning*
<br /> . . - . .
<br /> 51-5$::Mkkdtin:IttIPIE
<br /> Re : JUN 2 5 2024:.:.$14040.19tilsE
<br /> (50s)58;4141 S.:*;(503)'',5t84448
<br /> IrriiiikapanarianterAo/Pwittiotatiiititsn;ectiott , AtthitY#
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<br /> A..Propet.tOt '': ,,i.:ittratittatiot
<br /> Ufmtl liw-.144,w. 1.7.1iis l'.7:E Feke,:v ,re: ,[4:-CC-6-to1". ne- 1NSz 90) - 5Z(
<br /> NA* ',- Mailing Aqiiitik City State,and Zip (Area Code)
<br /> 11,,..14tat.P.mpertyl:foefitition
<br /> „. ...
<br /> , ,.
<br /> Legal Description
<br /> Tax Lot Aotogg0Iit-Lof Size
<br /> . .. .
<br /> .SbbdiviSierrNarne Lot
<br /> Black
<br /> . '
<br /> -
<br /> el7g(-11.-.
<br /> .......... :
<br /> Property AddressCity State Zip Code
<br /> Efireetionir*Iftapertyt
<br /> _ . .
<br /> : ..
<br /> C ExiatingPacil*/PrOposeit Faeilityllroteeltiformattart
<br /> " ,...- .
<br /> •IiirlwFiallity.; Proposed Facility Water Water A Sopply.F. ,Siogifianilytteildenee Sitip*p /
<br /> erni: iftesidence Oolitic . D..del,.&i '
<br /> Nu. etotBed-two*.
<br /> _. .. ..
<br /> Non* o-f.Beetroesita; 0:Peyote
<br /> Nain4
<br /> a Other 0 Other -
<br /> Well,SiniOS;.. 1:**,-4
<br /> D.,Type of
<br /> 0 'Mk Eirtiltia:ti(J0 .0 Renewal Permit ffili 14nrization14toriee for.:
<br /> i
<br /> Constntetienperinit
<br /> , p,„,„.,..,....,rit ,
<br /> , . .. CI fot4404a,nwalling
<br /> Repair Pertitit 0 PeOlirtTranskr i Ej-1*A4ditiamof Ow or More Bedrooms
<br /> IFIti Major :ET WOO L-1 EilistiOt System Evaluation Et Personal Hardship
<br /> 0 AlieratiotrPertnit 0,Record Review :E1 TemPotatylInusing.
<br /> 0:.Majat., 1::1 Miner 0 Other
<br /> E3 fConnecting to an Bilking System Never in Use
<br /> over 5.,yranlii);.
<br /> c p*0-PleaseSpecity.
<br /> . .
<br /> Ifti*requirEdfee4n$'aitaeh*eigs,iir*-itat fnglirdedwitkdik00pli64iio;it will Iiii***e4tilyincie ifiC000pteie, -
<br /> Pal,',4*9raOie-Card.at the cntranue'to the property ..Flag Ilicttst holes
<br /> osp•n*Aittiittiztl'ethitify that the infOtanagiO441avnfliinialte4iweOtreet,and hereby grant Marion Civik*i.atitherized.Fagent of the
<br /> Department of Effoit..0*iititt Quality;permission teettozeonto t40,4b001descrtliedpOperty- for tite sole purpose of thkappliea' tion,
<br /> . .
<br /> D,.,::, c „t, , s,...0....,..- 9 }9. e.,
<br /> Applka-pei.:-.Nania:- Please Print APPliOanea:;Phone-Vitinher DEO Lie,#-.(if,applicable):
<br /> ..•:-.)
<br /> ,
<br /> ei (cb, keipe k, .n: - lie. '97- 67
<br /> Applicant's Mailing Address;an.„ , : /-.-.7:- 2y /6- 7., e...., /
<br /> Signature Date
<br /> CCB# (itapplieahli):
<br /> Applicant ia the ELOwner D:.Ant.htniaodAepres-entatire DAtitherizationto Appl..Y'fhrinAdisehed:
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