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} <br /> Application for OnsiteCity <br /> .44k,,.44k,, For Use Only: <br /> Date Stamp: <br /> _:= Wastewater Treatment System - City of <br /> 111111 <br /> MARION COUNTY PUBLIC WORKS Date ReceivedReceived 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/Buildindasnection Activity# <br /> t <br /> A.Property Owner Information <br /> TIMOTHY&LISA SCHURTER 5174 SHANNON ROAD NE SILVERTON,OR 97381 (503)932-8007 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> ACRES 9.09 B.Le twos goe2o'a Description <br /> 9.09 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block , <br /> 5174 SHANNON.ROAD NE SILVERTON OR 97381 <br /> Property Address CityNState Zip Code <br /> LOCATED DIRECTLY ADJACENT TO SHANNON ROAD,NORTH OF INTERSECTION WITH HWY.213. <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ['Single Family Residence ❑ Single Family Residence ['Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms 0 Private <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D.Type of Application <br /> ❑, Site Evaluation 0 Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit 0 Permit Reinstatement 0 Replacing a Dwelling <br /> ❑ Repair Permit 0 Permit Transfer ❑ The Addition of One or More Bedrooms <br /> O Major 0 Minor 0 Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit ® Record Review 0 Temporary Housing <br /> ❑ Major 0 Minor 0 Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 0 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 /> Postthe orange card at the entrance to the prope 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 /> TIMOTHY SCHURTER (503)932-8007 <br /> Applicant's Name—Please.Print-Legibly Applicant's Phone Number DEQ.Lic.# (if applicable) <br /> 5174 SHANNON ROAD NE,SILVERTON,OR 97381 <br /> Applic..is Mailing Addre s <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 2 Owner 0 Authorized Representative ❑Authorization to Apply form Attached <br />