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Envlremmental Health Services Division ~ <br />Marion County Department of Public Health' <br />Salem, Oregon 97301 (588-5346)~ agent for: <br />Department of ~nwironm~ntel Quality <br /> <br />To'be submitted with application for <br />building pel~it or mobile home place- <br />ment permit. <br /> <br />Application to the Department of Environmental Quality <br />for a Permit to Q~q~truct a New or Eepai~ <br />a SuBsurface Sewage Disposal System <br /> <br />Permit Fees: ~ew ~ $75.00 ($37.50 with site evaluation) <br /> <br />Repaf~.Replace~ ,Alteration <br /> <br />A. REFERENCE INFORMATION <br /> <br />Name of Applicant <br /> 4712 Liberty Ed 5 <br /> <br />~aiiiug Aaa=ess' <br /> salell o~. 973C2 <br /> <br />City, State~ Zip Cede <br /> <br />Section Twp 8 Rge <br /> <br />Tax Lot or Account <br /> <br />Property A~R~ess <br /> <br />2W <br /> <br />'§'itc Evai~tton Serial Number <br /> <br />%nstalle='s Name <br /> <br />B0 ~ENmU~LDESCR;PT~ON <br /> <br />New Construetion~ x <br /> <br />Repair <br /> <br />Installation will serve: House x Mobile Home <br /> <br />Mobile Some Park <br /> <br />Co.narc!at Building ~ Other (explain) <br />Number of Living Units <br /> <br /> 3 <br />Number of Bedrooms -- ,, <br /> <br />Water Supply: Public Communtty__PrivateXGarba§e Disposal? yes <br /> <br />1. Proposed Subsurface Sewage Disposal System Plot Plan <br /> <br />Planning Evaluation -- Building Permit <br /> <br />~. Bui3ding Plans <br /> <br />hereby certify that the information contained in this application is true and co~rect <br /> <br />to the best of my knowledge and belief. <br /> <br />Et{-57 rev. t2/76 <br /> <br />Stgna~6re <br /> <br />Date <br /> <br /> <br />