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-ob S353
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<br /> .',..,', :,:.,. . -. Application for Onsite: . :Fooy.henly:,
<br /> .- -.----------4-....17-_- ; ' Wastewater Treatment System City of t
<br /> 1 we7IVI , —
<br /> Date-Reeeived. . . .. '
<br /> _79
<br /> Received14
<br /> OCT 04 2023
<br /> MARION'COVNTY.PUBLIC WOW,:
<br /> BUILDING INSPECTION DM:SfOSt Zoning bst.
<br /> SiOg.**10ift.c1NE•
<br /> .„ Fit MARION COUNTY
<br /> gaient03.97305.
<br /> BUILDING INSPECTION
<br /> (504588-5147 Fa :..(5,03).-,5$8494/1: . Rtteipt# .
<br /> , Activ• 144:
<br /> Ivilft..:co:ititaiiamot:u§/P8Vigilifiliiielittotetion -,
<br /> A.Froperty(*oetinfortnation-
<br /> (k.qe-Kall5Ity 1,6 e Po . 0x. :471.51/ &..('-e_.(c,,, ` ?'. 2‘ For-Ys.70- /.€7eZ
<br /> Name Mailing Address city„--„State,ond:Zip: ,(Area-Cedo)PhOne#
<br /> E.,..Legal FropertyLreterilition
<br /> . . .
<br /> ,
<br /> tegaltteiCriptiett
<br /> Tax Lot Acreage iit Dit Size
<br /> :-,Skihdiliision:Name,
<br /> Lot Block
<br /> . .
<br /> .$.-Z ) J.a..vt c c_x_
<br /> Property Address City.
<br /> State Zip:Cade
<br /> Direetiona.toPropertir
<br /> " -- -
<br /> C Existing FaCillty/ProposeitFarilityiWaterchirormaticin
<br /> Eaiiiing:Foriittyt‘
<br /> ProposedIecitity:: Water Sappir
<br /> EISingle:Rinillyiltest4enee Ern
<br /> Mk
<br /> 'Vitt&F4iiiyi =Won=
<br /> Naine
<br /> . ..Number_.----- -.___.-Bed ,,_
<br /> of rooms- Naii*rerB . " itio 0 :Ptivate
<br /> 12 Other . 0.Other Well,Spring,Shared
<br /> Ix'TypebrApptiotion
<br /> r.1,site.,araloitiod 0 Renewal Permit DAllthilon`Notite for:
<br /> igr:Constr!4#0it porta. 0:Ni.OlitApipsiaiement . 0:1?,:eplaeitig.a Dwelling
<br /> 0'*pair,Permit 0. P.., ,.Ottroit Transfer El'Tho'4dditionotOne or More*Ornems
<br /> 0:-Major E3-.Wm' 0 Eltitckg$Ateill-Erituatiott. D.Personal Hardship
<br /> 0 Alteration Permit 0 Record Review 0:Temporary Housing
<br /> 0 Major Q:Minor 0 Other• 0 Cniumeting to an F,idating System:Never-inAlse.
<br /> ,. ..
<br /> -(tiy.et5,yrs old);
<br /> 0 Other—Please-Syr:COY:
<br /> fidie-reottedfre g,"-----T, .. Iiiktacknientr-.int.,.tiotindudect wilittlits‘iippliediion-it will be returnerfloyen as incomplete
<br /> . .... _.., . ., . . • '' :. . .:.
<br /> Pdfttit orangeicar4lttlie:datraitae..te.tiad. "property,Fla -,theleaffitilea. ., . . . . . .
<br /> • Sy 4iy,aiipiatni*J dettitr that the itithiMatiott[havefurniahetf fo:eortnet,and.hereby grant Marion County,inthorizect atetitg0.0
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<br /> Rephrtment of EnyirOmpatitIVInit4y;figiliftiOil:tO eittgr Onto'tho abOvellescrilied#Operty for:the'rolt.PinpOoe of this application.
<br /> k.-...,..evo , o4' .: 1( . . ::if> A .. _41:-..,.
<br /> Applicant's Name,,PleaselrintLegiblY Appdieatics Phone NutOber DEQ Lie.#firapptietible.).
<br /> .0 "CN')e Z 1 1 --Ct ke 17 e ie, ne- g7.36.7
<br /> Applitant7aMitilingAddress
<br /> „..71.
<br /> .. .
<br /> Signature Date:..
<br /> . r
<br /> Data: / CCTS4/(i6f applicable) /
<br /> 100144is-the Downer '0,14tithorizedItivresentative 0:Authorization tnApply ferinAttiefietf
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