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~nvirom~en~al Health Services Division <br />Marion County Department of Public Health <br />Salem, Oregon 97301 (588-5346), agent for: <br />Department of Environmental Quality <br /> <br />To be submitted with application for ~/i <br />'building permit or mobile home place- <br />ment permit, <br /> <br />Application to the Department of Environmental Quality <br /> for a Permit to Coastruct a New or'R__e~air <br /> a Subsurface Sewage Disposal Syetem <br /> <br />Permit Fees: New - $75.00 ($37.50 with site evaluation) <br /> <br />Repair, ReplaEp~Alteratiom - $25.00 <br /> <br />A. REFERENCE INFORMATION <br /> <br />Name of Applicant <br /> <br />Mailing Address <br /> <br />City, St~e, Zip COde <br /> <br />Site Evaluation serial Number <br /> <br />Section <br /> <br />oper't~ AddreS~ <br /> <br />Installer's Name <br /> <br />GKNERAL DESCRIPTION <br /> <br />New Construction <br /> <br />Installation will serve: <br /> <br />Mobile Home ~z/ Mobile Home Park <br /> <br />Commercial Building ...... Other (explain) <br /> <br />Number of Living Units <br /> <br />Water Supply: Public ~ Community <br /> <br /> Number of Bedrooms ~ <br />Private__Garbage Disposal? <br /> <br />1. Proposed Subsurface Sewage Disposal System PlotP%am <br /> <br />2. Planning Evaluation -- Building Permit <br /> <br />3. Building Plans <br /> <br /> hereby certify that the information contained in this application is true and correct <br />Permit ~o.to the best of my knowledge and belfef~ ~ ~ :~ <br /> Signature~ <br /> <br />E}1-57 rev. 12/7~ <br /> <br /> <br />