|
. . . .. . „
<br /> . ,
<br /> . . . _ c6 z Ev 001, lot
<br /> . ,
<br /> . .., .
<br /> ......„.._ - 2 3 L
<br /> . , .44....„. ... . Application for:Otisite Dates
<br /> Wstewater Treatm
<br /> ----, 77.-o aent System '-- Lcvi I .
<br /> .,..... _ ,_...... _.
<br /> • •. ,., ..
<br /> . .. ..;. :, MARION COUNTY:09;tpe WORKS ' 1 r-,)I JUL 2 6 2023 Li
<br /> ,
<br /> -.: . ......... ..., ' Btatig00.01sPzowig,-nmsxoN"
<br /> MARION COUNTY
<br /> . s $1$6S..ilv..i.170#14A
<br /> Salem ult 4.7305':
<br /> BUILDING INSPECTION
<br /> . 0031 81i. 1A7.. 74.V.0047P48 -• -
<br /> www:o.mariOnm:us/PWIthrildiiidInsOection
<br /> , .
<br /> ' . , ,..,.. . , . ....- ...—...
<br /> ..,,,,, .---;-4..=?:: : ;:si.fi,A-iiir;,-(,n%,;st,',:wek,.?. .%if4w,,V.it.s.r':g;17.1.
<br /> . .' • , *Troger4-,c,,,, Or..10:03710pn4g..745.1-7:44.*.4,.4,....,..:,:o.:4,. g.,.,,:„A*,,,- ....,u,,,„,,,,,gp,,,,,,,„„,,,„„„ ..,,.„.,,,:„,,.,,,,,,,,,„..,,,
<br /> /4
<br /> • .
<br /> ...4A—cA/ .0FA/4.I/
<br /> lie:
<br /> . , : . ...... : .
<br /> (5063 .11ctrti 'as
<br /> Name - MaiiiiigAddress
<br /> •
<br /> '..1••.'' ' : . .ElaW : ox_. q7361.:
<br /> 6.71-11 - - ' ., ..506 3Y 8
<br /> C.i,v,Atate,:;an„ jp,,,,, (Area Code)Phone#
<br /> , .„,„„,,,,,,;,,,,,,,,vv,v,. .±,A.A. .::,,,,pwamtvige,3-..tv.;;56,4.?,N::
<br /> . littfiligitagethikeii :, ;"-'04,-.1:PI•14,V1 -•4; ;'-.-,='Y'z::5;..g..?',:t'iRif,:e2,,e;:-64.;44..Aw. ,&07,11,',...,.af.,5.2,21- z,, ,f.ii,*5&:.,,. .4. ,,,,;-.,!1... ...,.?b•,,,... .
<br /> . . 150 6 3 -- kik tiet,-- LA .:4/7E. -
<br /> ..s. ' SI/ kik/. OK ...7 71 el: •
<br /> . .. .
<br /> • •- . rivjperty.A4dkesS ' City State Zit.Code. •
<br /> Partel# ' Tax LOt Acreage or Lot Size
<br /> - , Direttionsin Property: : . . : , - : . —
<br /> . 1 rq frl rie: 'Z' 'r-rGkkt 441e•
<br /> . ,
<br /> , . . . .... ...,.. .,.. .
<br /> " ' ' 4-,t,:,,„,-,„..-t;,„„T,..,",,,,,,,,-,-,,,-,.,..,-,,a.,,,.--,*,.,ia...;,;----,.v,,-...(,w---a,.„,,,,ya,r,.„,--A-if„wyQ,, qfRalw,zgpz.o-,yr.q.. z.gwgtmgtq_N,Ri,c':m4.:i•we::-,.v::;,..,
<br /> : .• - '. • ',,,,,-.:„..,:...„,..„....„.„,„.„-,-„„,..,,-,,...„....„,-„,.„,,,,,,..„..„...„..„.,...„...„-„,,,„,..„.„.„,..„.,,,...„.„...,,,,,„...„:„..„,„„,„:„..„,..,„.,,,4,..,„„,. „..,:,...„.........,.._.. ......, ... . ...
<br /> , - Etis•thigResideritiid:. Proposed Residential r . Existing Commercial: Proposed commercial; Warer84p1*;
<br /> ' CiPtibl..e
<br /> 4+
<br /> Number ..., Nuniberof.Ptuployeesr .4.4
<br /> Number of Bedrooms NuMber of Bedrooms ofEmployeest seating Sestlbg • rri ate
<br /> ,. . :
<br /> " • ', , CeOpri.rtg,Shared
<br /> • „
<br /> • ..
<br /> ' . * . tEr)•T'7". .74..'„tT,4Wt:*ttZir'ztnVI-".eg3'.4iga;'•*diaa'OV;4I,:§t'itl'''74ee•4:)F',..f4tij' 'P:,7jLT!S.ITiaf-,i'',..„CtV,,F-e,' .';:-V-").
<br /> • . ..
<br /> Sik Evaluation , 0 Renewal Permit .0.Antherization:Nofite,fott, .,• - '
<br /> ,• Elj Construction Permit 0.PerrnitAeliptatetnent E:I..1:04*frigiat*cliing,
<br /> . . ' ,• 0 ROW Permit : 0 Peril*Transfer: : '' '':Ely-The•ka4itiekof One or More Bedrooms
<br /> El Major .0 Minor 0 Existing System Evaluation .0.Peisenatitatheliip.
<br /> ,.
<br /> 0 Alteration Permit, - ..0 Record Review D Temporary Housing
<br /> 0 Major 0 *tor 0 Other' ;0.1 Connecting to Existing System Never in Use
<br /> (over 54r6..pid): ' •
<br /> El pther4P.)e*e*ecifV' .
<br /> . ,
<br /> Ifthe reqwredfee and eittacfintotts dre-not-*lidc4oilkthk cl-Pi?qcgliot!, itildl?be rettimoo,you fis...mcomplete.
<br /> Post.the tiiiiiiireard atthe:;ftirance tOiliiipionertylllakthe tar holes. " _ .
<br /> BY my signature,I IkOeitifY*04e-Alf*-14:44:00e furnished-iS:cOrectr: nd'herehy:grantIlari,. Ott County,authorized:agent of the
<br /> e
<br /> Department OfErivironmentainalitYpiiiiiiia*.th.oikter onicf*0.20.0y ii007*:4;otop***-..titp:ok-.00pOS.application
<br /> . ' • -- - . .. . _„ „ . . . ,
<br /> - ' -•-'!:: '.: .. '' • ' ,!.,:'. _ , :4,.. 4g.l...,,,...4(523ts, _ i 3.7;4- 3)/. .
<br /> ,
<br /> ' . . •, e—Please Print L/egibly AoolicaisPlimeliiiitthor „. ' ::.:, , „ DEO-Lit.#(ifapplicable) -
<br /> — ---4-?W s--(5'40- c4- : Va/43- e'R ____
<br /> App'eant'sivfaiiing:Address, _ . '..:''., . '' ': •,''',.:-/,;;.•745,.;',R. ,,-,,,,,,-,/2'.' , . . ::,‘,2,-..:7,41 '1,,,,,4F.,0-C.,' ' '
<br /> ,--.12S4.242.3 • - . ' - , ,i---s..„a . , _-_.-__
<br /> . ' Si -.. - 'G%' .-...'. • Date: CCB# -(if applicable)
<br /> . . :..
<br /> ApPlicart- t is the 0 Owner 0 Anth prized:Reprepentaiive Omit attached)
<br /> GABUILDINaNSPECTIONWORNISNSEPTIOS41.-:QNWE APPL JlitY2023 REV 6:231,DOcZ•gev:.t/15,,31t 8;6/22;6/23
<br /> . .
<br />
|