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Department of Environmental Quality ['i ' .. ..... ~"'"~"~'~ c.[-' <br />1234 S. ~. Mo~ison '~ ::..... <br />Portland, Oregon 97205 <br /> <br />Land Quality <br />COunty <br /> <br />Application to the Department of Environmental Quality <br /> <br /> for a Permit to Constr~c~ a <br /> <br /> NeW or Re__~a Subsurface Sewage <br /> <br /> Dis~sal Syst~n'' <br /> <br /> Permit Fees= New $30.00 Repair, Alteration $15.00 <br /> <br />REFERENCE INFORMATION <br /> <br /> ~ ~ .,~ ! ~~ ' T~ ~t or Account ~ ....... <br /> <br />City <br /> <br />Installers N~e <br /> <br />B. G~NERAL D~SCRIPTION <br /> <br />New Construction~ <br />Installation will serve: <br /> <br />Coramercial Building <br /> <br />No. of Living Units ...... <br /> <br />Water Supply~ Public <br /> <br /> ~epair <br />House ..... Mobile Ho~e <br /> <br /> Other (Explain)_ .. <br /> <br /> NO. Bedrooms ~ <br /> _Co~munit~ Private <br /> <br />Mobile Home Par~ .... <br /> <br />/Garbage Disposal? <br /> <br />~Q~IRED EXHIBITS <br /> -" <br />1. Proposed Subsurface Sewage Disposal System ...... <br /> <br />Planning Evaluation - Building Permit .(Logal .O~tion) <br /> <br />3. otho~r (Local Option) Buildi~l~ Plans - <br /> <br />I hereby certify that the information contained in this application is true a~d <br />correct to the best of my knowledge and belief. <br /> <br />Permit No. ~_~..~' ~ <br /> <br /> Date <br /> <br />'Signature (~-/ ) <br />Date.. <br /> <br />Interim Form 91 <br /> <br /> <br />