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Environmental Health Sel~ices Division <br />~rion County Department of P~blic ~{ealth <br />Salem, Oregon 97301 (588-5348), agent for: <br />Department of Environmental Quality <br /> <br />To be submitted with application for <br />building permit or ~obile home place~ <br />ment permit. <br /> <br />Application to the Department of Environmental Quality <br />for a Permit to Construct a Now or P~ <br />a Subsurface Sewage Disposal System <br /> <br />Permit Fees: New - $50.00 ($25.00 with site evaluation) <br /> <br />Repair, Alteration - $15.00 <br /> <br />A. Rk~EP~NCE INFORNATI~ <br /> <br /> Lloyd 'Sieg le <br />Name of Applicant <br /> <br /> ~ic.~ 6{--96 l{iver <br /> 'ASdr ss <br /> <br />City, 8tate~ Zip ~e <br /> <br />Section <br /> <br />Tax Lot or Account # <br />Lot Size 16s x 543 <br /> <br />Property Address <br /> <br />GENEPJ~L DESCRIPTION <br /> <br />New Construction <br /> <br />Installation will serve: <br /> <br />Corm~rcial Building <br /> <br />Number of Living Units <br /> <br />~AL%ter Supply: Public <br /> <br />In'Staller's 'Hsme ' ' <br /> <br />x Repair <br /> <br /> House x [,Dbile Hcme <br /> Other (explain) <br /> <br />Community <br /> <br />Mobile Home Pa~k <br /> <br />Number ofBedroctmq 2 <br /> <br /> Private x Garbage Disposal? <br /> <br />c. a U RED EXHB TS <br /> <br />1. Proposed Subsurface Sewage Disposal System Plot Plan <br /> <br />2. Planning Evaluation ~ Building Permit <br /> <br />3. Building Plans <br /> <br />I hereby certify that the infor~%tion contained in this application is true and correct <br /> <br />Permit No. ~q3 <br /> '" ¢~igp,~e (o~nar/ihSt~r) <br /> <br />EH-57 7/74 Date <br /> <br /> <br />