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HEALTH DEPT. <br /> * ~.~,~ \ -. <br /> ~t~,'.' S~,~ ?. ':, ;, ~ <br /> <br />~v~nt~l He,th Division, ~ion C~ty He~lt~~~2~ - <br />~z~ Street N.E., Sal~, ~egon 97301 <br /> <br />Subject: Requeet for site evaluation of property listed below as required by <br /> OregOn Administrative Rules, Chapter 333, sections 41-001 to <br /> (pre-sale information), <br /> <br /> (address) <br /> <br />Evaluation requested by <br /> <br />(name and address, if other than owner) <br /> <br />Property address and/or description land marks, etc. <br /> <br />Section Range, <br /> <br />Township Number of acres__ <br /> <br />, .P~oposed land ,~se <br /> <br />(a) S~bdivision <br /> <br />number of lots average size <br /> <br /> Residential <br /> / <br /> (sPecify: ~, multipi'e, mobile homes, caz~, <br /> etc. ) <br />(b) C~ercial development <br /> (type of business and ~mher of <br />(C) Partition <br /> (s~ctfy number of parcels proposed and use intended) <br />(d) Proposed building site <br /> (not requiring ~Ab-division or partition, proposed <br /> %lse) <br /> Proposed method of sewage disposal ~e?7~/d <br /> if' <br /> (spec y septic tanks or other methods) <br />(f) Proposed water supply ~/F.Z ~. ....... <br /> <br /> (Specify: public, cumm~nity or individual w~/1s on each proposed tract) <br /> <br />NOTE: Non-refundable $20 fee ~ .~. ~.~T~ <br /> enclosed. (Signature) <br /> <br />~-5o ?/72 <br /> <br /> <br />