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Application for Onsite For City Use Only: Date Stamp: <br /> All ;,4z. <br /> Wastewater Treatment System City of_ <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING,INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PW/BuildingInspection Activity# <br /> A.Property Owner Information <br /> CMP ROTH FARMS,LLC 6791 RIVER HEIGHTS LANE Salem,OR 97306 (503)932-3444 <br /> MATT 8 JAMIE ROTH <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> ITI <br /> ACRE 93.46,19-20:DEFERRED ADDONAL TAX LIABILITY.SB125.18$48.43 071W06.0 300 93.46 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 4914 SHANNON ROAD NE SILVERTON OR 97381 <br /> Property Address City State Zip Code <br /> Directions to Property: LOCATED DIRECTLY ADJACENT TO SHANNON ROAD.NORTH OF INTERSECTION WITH HWY.213. <br /> C.Existing Facility/ProposedFacility/Water Information - <br /> Existing Facility: Proposed Facility: Water.Supply: <br /> Single Family Residence ❑ Single Family Residence ❑Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms 0 Private <br /> [] Other ❑ Other .Well,Spring,Shared <br /> D.Type of Application . <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> ❑ Major ❑ .Minor ® Existing System Evaluation D Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review 0 Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other 0 Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> ❑ Other—Please Specify <br /> If the required fee and attachments are not included with this application, it will be returned to you as incomplete. <br /> Post the orange card at the entrance to the property. Flag the test holes. <br /> By my signature,I certify that the information I have furnished is correct,and hereby grant Marion County,authorized agent of the <br /> Department of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> MATTHEW ROTH (503)932-3444 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lie.# (if applicable) <br /> 6791 RIVER HEIGHTS LANE,SALEM,OR 97306 <br /> Applicant's Mail.ng Address <br /> 1 <br /> et/�d/il <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the©Owner ❑Authorized Representative 0 Authorization to Apply form Attached <br />