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034, e:1, 5,8) 5 ,i <br /> . . <br /> Application ifot. ()mite. <br /> uatestamPRECEIVED <br /> 7.774.- agar Wastewater Treatment System <br /> . . <br /> IiiiMuoN.COUNTY PUBLIC WORKS: JUL 2 6 2024 <br /> ittatioiNg INSPECTION DIVISION <br /> 5155 SiKerton Rd NE <br /> S:ileac-OR97305 <br /> (503),5885147 F'.4.(510)S88-7948 <br /> Istww:eo,martomor.us/PW/Bnildinkinsueetinn <br /> A.PrOpertv-Ownerldfonntition <br /> 00.. (.41Z CO`' .4nOri.,ti.N 17 12 krAKA2r.Lel <br /> Name ' — Mailing Address <br /> lAurato., 0 V•--. 0,Stiat-ir 775Z- <br /> City,State,and Zip (Area Code)Phoneg. <br /> 11.14gat.Properfy Description <br /> 17372,A,' A e0ji.Ntr I IA- : 4.c .A0A.ro:Nrc <br /> ....... . 0 -- ,:. :. . <br /> Property Address City State Zip 'Ade. <br /> btAlint eCi .. OL-1(60Ct. 0,I-S iiNe. <br /> pared,.# . Tax Lot Acreage•or Lot&ie. <br /> Directions.to.Property: <br /> c ExiSting,Faciiity/T.roposed.Facilityi.:W4ter Information <br /> Existing lielidentialt Proposed Residential ExistMg.tommerciAb Promised Commercial: Watup:Supp41 <br /> y 1. <br /> dpublie co010,,w,:•141; -Name: <br /> NuMber,of Employees/ Number of Ernoloees/ 0 Private <br /> NuMber'iff Bedrebnis Number Of BeditiornS <br /> . - . Seatifig S.4*ing! <br /> WelLSOriftg,Shared. <br /> A"t7W of Application. <br /> Di Site Evaluation 0 Renewal Permit 0Authdrii‘atitn Notice:Or:: <br /> E1 Construction Permit 0 Permit Reinstatement .E1 Replacing a Dwelling <br /> .14 Repair Permit D Permit Transfer 0 The Additiottof One or More Bedrooms <br /> 0 Major ET,Minor 0 EXisting y,§ttrii- Valtiatibn 0 Personal Hardship <br /> 01 Alter-aim Permit 0 Record Review 0 Temporary Housing <br /> 0 Major 0 Minor. El Other 0 connecting:to an Existing System Never 4 U.Se <br /> (00.511'$:ad) <br /> 0 Othet—.Pfeuse:SpeMly <br /> ffrhe'relgiitdjiu.ii*I0dockireirty are not i4cludeciwith this application ['twill beiwiitireit.tes.);01c.-6.•incgiiipidie. <br /> Post the orantte eard:at the.entrarice to'the tiiiiiiefl*. Flag the test holes. <br /> By my ticznature,(certify that the infortnatiOrtit have ftirriishedisvorrect.,and hereby grant Marion cnOty;.adthdrized:agentof the <br /> Department ofEnvironmentgOdality;.perMkaion toenteroitto,the above described property for thesoiepOroofthis application.. <br /> c) <br /> ck,c-)e" <br /> \Nc' ‘ ,s s \ ct3-1Nb ,6B1S\.: . <br /> App icant!s<Name-Please Print Legibly Applicants Phone Number riEQ,Lic.4:(if applicable) <br /> ‘ciko--3'\ VA 0:0,,r Ov. .0.y.vo, -C,0-err(V .-:-.04.—. 5%tyy.00t,h.Wlit ky,,calk <br /> Applicant s.'whit Address _ Einaili. <br /> Signature Date:. CCE4 (it:applicable) <br /> t-frl-PS:liMARIONCOUNTYGCC=MYLSHAREPOINTLCOMiPERSONALIBREICH CO MARIONi011. US/DOCUMENTSME4KTOPIS-0,1 ON$Itt/Vet.iOLY <br /> 2024 REV 7124'.DOCX Reii,IJ15,3113;6/22;6.(2,31 <br /> L <br />