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Environmental Health Services Division <br />Mari~ County Department of Public Health <br />Salem, Oregon 97301 (588-5346), agent for: <br />Departmemt of gnvirorn~ental Quality <br /> <br />To be submitted with application for <br />building permit or mobile home place- <br />ment pe~it. <br /> <br />Applicatiom to the Department of Environmental Quality <br />for a Permit to Construct a New or R~epair <br />a Subsurface Sewage Disposal System <br /> <br />Permit Fees: New - $75.00 ($37.50 with site evaluation) <br /> <br />~lace; Alteration - $25.00 <br /> <br />A. REFERENCE iNFO1AMATION <br /> <br /> ~URIN ~ VERALOKTEFF <br />Name of Applicant <br /> <br />Section ~ Twp <br /> <br />Mailing Address <br /> <br />City, ~tat~, zip cod~ <br /> <br />Tax Lot or Account # ........... <br /> <br />Lot Size i ACRE + <br /> <br />Property Address <br /> <br />Site Evaluation Serial Number <br /> <br />GENERAL DESCRIPTION <br /> <br />New Construction ~O~RR <br /> <br />Installation will serve: House ,, ,X,, <br /> <br />Installer's Name <br /> <br /> Repair___ , <br />Mobile Home Mobile Home Park <br /> <br />Commercial Building __ <br /> <br />Number of Living Units <br /> <br />Water Supply: Public <br /> <br />REqu IPdSD EXHIBITS <br /> <br />2. <br /> <br /> Other (explain) <br /> <br /> 1 <br /> <br />__ Community__ <br /> <br /> Number of Bedrooms ~ <br />Private ,~,, Garbage Disposal? YES <br /> <br />Proposed Subsurface Sewage Disposal System Plot Plan <br />Planning Evaluation -- Building Permit <br /> <br />Building Flans <br /> <br />I hereby certify that the information contained in this application is true and correct <br /> <br />to the best of my knowledge and belief. <br /> <br />Pe ttNo. <br /> <br />EH-57 rev. 12/76 <br /> <br />Date <br /> <br /> <br />