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Environmental Health S,arvices Divisioff '' <br />~{arion County Dep~9~iTnent Of Public Itealth <br />Salem, (h-egon 97301 (588-5346), a~qent for: <br />Departn~nt of Envirol~mental Qu~lity <br /> <br />TO be submitted with application for <br />building per~,~it or n~bile he. me place- <br />~t permit. <br /> <br />Applicaticn to tile Dep~nt of Enviror~nental Quality <br />for a Permit to Construct a Nc~, or Repair~ <br />a Sub~lr£~ce Sewage Disposal Syst~n <br /> <br />Perr~it Fees: New - $50.00 ($25.00 with site evaluation) <br /> <br />Alteration ~ $15.00 <br /> <br />Section ~/ T _~__ R / ~ <br /> <br />Tax Lot or Account <br /> <br /> si e ....... <br /> <br />pr~per~y Address / <br /> <br />Instal!er's N~ne <br /> <br />B. C~RAL DESCRIPTION <br /> <br />New Construction ~' R~pair <br /> <br />Installation will serve: House /Nobile H~ne <br /> <br />~bile Home <br /> <br />Commercial Building__ <br /> <br />Nunlo~r of Living Units <br /> <br />Water ~pply: Public <br /> <br />Other (explain) <br /> <br /> / N%~aber of ~i~dro~s _ ~ <br /> <br /> Crm~unity Pri%~te ~/' Garbage Disposal? <br /> <br />C. ~qF~l!~ ~{IBITS <br /> <br />Proposed Subsurface Se~o~e Disposal System Plot P!~u <br />PL%uning Evaluation -- Building Permit <br /> <br />~ilding Plums <br /> <br />i hereby certify 'that the information containcwl in t~ application is true and ~rrect <br />to the be~t of ~ ~owle~e a:~d belief. / / ~ ~ <br /> <br />Pemit No. ,Bq~ S,i~e~ifl~al!er) <br />L...- 7/74 Date <br /> <br /> <br />