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• (9 14):39bS5 f, • Application for Onsite For City Use Only: Date Stamp: Wastewater Treatment System City of OMDate Received MARION COUNTY PUBLIC WORKS Received by D IJ V BUILDING INSPECTION DIVISION Zoning by Ti 5155 Silverton Rd NE — SEP 1 0 2021 `' Salem OR 97305 Fee (503)588-5147 Fax (503)588-7948 Receipt 4MARION COUNTY y w'w« co.marian.or.us/PW/BuiltlingInspection Activity BUILDING INSPECTION A. Property Owner Information CMP Roth Farms, LLC 6791 River Heights Lane S. Salem.Oregon,97306 NA Name Mailing Address City,State,and Zip (Area Code) Phone m B.Legal Property Description 072W 13CB00700 Parcel 2. Proposed PP 2021 700 1.29 Legal Description Tax Lot Acreage or Lot Size Roth Farms Partition Proposed Parcel 2 Block Subdivision Name Lot Q.,6b SH .&I-fV;etd t&a nr= r Iltnne ssi Salem - 7 3�J Oregon 17- Sattn3-vitm Ruud City State Zip Code Property Address Directions to Property: Sunnyview Road to Access. Currently Crass Seed Field. Real Estate For Sale Sign on Howell Prairie access point. Sze "449/f?�.I lase Ni. 2 - 2 2 C. Existing Facility/Proposed Facility/Water Information Existing Facility: Proposed Facility: Water Supply: ❑Single Family Residence X Single Family Residence ❑Public 4-Bedrooms Name Number of Bedrooms X Private Well ❑ Other 0 Other D.Type of Application X Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: 0 Construction Permit 0 Permit Reinstatement 0 Replacing a Dwelling ❑ Repair Permit ❑ Permit Transfer ❑ Major ❑ Minor 0 Existing System Evaluation 0 TheAdditionof One or More Bedrooms ID Alteration Permit ❑ Personal Hardship 0 Record Review ❑ Temporary Housing ❑ Major ❑ Minor ❑ Other ❑ Connecting to an Existing System Never in Use (over 5-yrs old) ❑ Other—Please Specify lithe required fee and attachments are not included with this application, it will be returned to you as incomplete. Post the orange card at the entrance to the property. Flag the test holes. By my signature, I certify that the information I have furnished is correct,and hereby grant Marion County,authorized agent of the Department of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. Owen Von Flue 503-932-7698 N.A. Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic. # (if applicable) 5146 Ike i ney Road NE,Silverton,Oregon 97381 Applic is Tailing Addres 4-1 8-13-2021 156990 Signature Date: CCB# (if applicable)