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Envtroranental Health Services Division <br />Mario~ County Department of Public Health <br />Salem, Oregon 97301 (588-5346), agent for: <br />Department of Environmental Quality <br /> <br />To be submitted with app].ica~ion for <br />building permit or mobile home place- <br />ment permit. <br /> <br />Application to the Department of Environmental Quality <br />for a Permit to Construct a New or'Repair <br />a Subsurface Sewage Disposal System <br /> <br />Permit Feea: ~.ew - $75.00 ($37.50 with sits evaluation) <br /> <br />Repair, Replace~ Alteration - $25.00 <br /> <br />A. REFERENCE INFORMATION <br /> <br />__Stephen L. StqFdiY~j%_. <br />Name of Applicant <br /> <br /> ~5.61 Li.~tle. Road SE <br />Mailing Address <br /> <br /> ~ 92525 <br />City, State, Zip Code <br /> <br />Site Evaluation Serial Number <br /> <br />GENERAL DESCRIPTION <br /> <br />New Construction <br /> <br />Installation will serve: <br /> <br />Commercial Building <br /> <br />Tax Lot or Account # <br /> <br />Lot Size 19.8 acres <br /> <br />Property Address <br /> <br />Installer' s Name <br /> <br /> Repair <br /> <br /> House .... X Mobile Dome <br /> <br />___Other (explain) <br /> <br />Number of Living Units ~. <br /> <br />Water Supply: Public __ Community <br /> <br />REQUIRED E~IIBITS <br /> <br />1. <br /> <br />2, <br /> <br />3. <br /> <br />Mobile Home Park <br /> <br /> _Number of <br /> <br />· Private X Garbage Disposal? no <br /> <br />Proposed Subsurface Sewage Disposal System Plot Plan <br /> <br />Planning Evaluation -- Building Permit <br /> <br />Building Plans <br /> <br />I hereby certify that the information contained in this application is trne and correct <br /> <br />to the best of my knowledge and belief. <br />Permit No. <br /> <br />EH-57 rev. 12/76 <br /> <br />s~gnature t .... <br /> <br />Date <br /> <br /> <br />