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~Environmental Ilealth Services Division <br />~t~rion County Department of ~blic Health <br />AI~, ~e~n 97301 (588~5~]), ~en~ for: <br />~p~nt of ~virom~ntat ~lality <br /> <br />To be submitted with application for <br />building per,mit or mobile h~ place- <br />rr~nt perTnit. <br /> <br />&pplicaticn to the Dcps~mnt of Environmental Quality <br />for a permit to Constr%lct a N~ or P~r <br />a Substtrfmce S~e Disposal System <br /> <br />Permit F~s: Ne__~ - $50.00 ($25.00with site evaluation) <br /> <br />~c~,ai,r~ Alteration - $15.00 <br /> <br />A. RE]~g~CE INFORMATI©N <br /> <br />N B[ hm lican' ' <br /> <br />Mailing Address <br /> <br />City. ~tate, ZiP ~'~ ' <br /> <br />Section ~...~. T <br /> <br />Tax Lot or Account <br /> <br /> Siz <br /> <br />PropertY'Address <br /> <br />Installer's N~ne <br /> <br />B. C~?iNS~tAL DESCRIPTIC~~ <br /> <br />New C~nstruct ion <br /> <br />Repair <br /> <br />Installation will serve: House .~-~bile Home Mobile Home Pa~ck <br /> <br />Conmercial Building__ Other (e~lain) <br /> <br />Numl~r of Living Units / <br /> <br />%~ater Supply: Public ~ity <br /> <br />Private /"C~rbage Disposal? ,.--~ ~ ~ <br /> <br />C. PJ~_QU I?~D ~i~{IBITS <br /> <br />t. Proposed Subsuzface Salvage Disposal System P].ot Plan <br />2, Pl~nningEvaluation -- Building Permit <br /> <br />3, [~ilding Plsms <br /> <br />I hereby certify tz~.t the information containc-d in -this application is true and correct <br /> <br />to 'the best ef my knowledge m~d belief. <br />3PeL~it No. %~ <br />Issued Q - t~g~ <br /> <br />~": =~ 7/74 <br /> <br /> <br />