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Environmental Health Services Division <br />~rion County Department of l~blic Health <br />Salem, Oregon 97301 (588-5346), agent for: <br />Depar~ent of Environmental Quality <br /> <br />To be suhuitted with application for <br />building pern~it or mobile l~3ms place- <br />rf~Jlt poled t. <br /> <br />Application to the Dependent of Enviror~mental Quality <br />for a Permit to Construct a New or ?~_r <br />a Subsurface Sewage Disposal System <br /> <br />Pon~it FEES: Ntw~ - $50.00 ($25,00with site evaluation) <br /> <br />R%Dair~ Alteration ~ $15.00 <br /> <br /> Cliff Dural <br />Narn~ of Applicant <br />4712 Liberty <br /> 8991 Edclif~ Ct. SE <br /> <br />Ha~ling Address <br /> <br /> Salem <br /> <br />City~ State~ Zip C~kde <br /> <br /> 12 & 13 <br />Section T 8 R 2w <br /> <br />Tax Lot or Account # <br /> <br />Lot Si?~e irregular <br /> <br /> 8991 Edcliff SE <br />Property Adch*ess <br /> <br />Installer ' s <br /> <br /> Mobile Home P~k <br /> <br />B. GL~L~JLL DESCRIFrI(1N <br /> <br />N~v Construction <br /> <br />Installation will serve: <br /> <br />Commercial Building <br /> <br />Nunt~r of Living Units <br /> <br />Wnter Mupp] y: Public <br /> <br />x Repair <br /> <br /> House x 5.~obile Home <br />Other (explain) <br /> <br />Ccramunity <br /> <br />N~mnber of B~cms 3 <br /> <br /> Private Garb~4~e D~s~sal. yes <br /> <br />C. ~J,IIRED }72{}{IBITS <br /> <br />1. Proposed Subs~r£aCo Se~e Disposal, Systam Plot P!~m <br /> <br />2. Planning Evaluation -- Building Permit <br /> <br />3~ Building Plexus <br /> <br />I h{reby certify t_~.t the ]nfo~%t~on contazned in ~h~s~pl~catlon is t~o ~d corr~t <br />to the best of ~ knowle~o and oelief. <br /> <br /> Si~t~e (o~er/inst~ller) <br /> <br />Date <br /> <br /> <br />