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Nmrion County Department Of P~Ifa Health <br />S~lem~ O~egon 97301 (588-5346), egemt for: <br />Department of Enviro~m~nta~ Qua!i~y <br /> <br />To be submitted with appli~aticn for <br />building permit or mobile home place- <br />ment permit. <br /> <br />Application to the Department of Envirommental Quality <br /> a Subsurface Sewage D~sposal System <br /> <br />Permit Fees: ~w - $75.00 ($37.50 with site evaluation) <br /> <br />~epair, Repla¢9,'Altera~on - $25.00 <br /> <br />REFERENC~ INFORMATION <br /> <br />Name of Applicant <br /> <br /> 5745 S~; Howe!Ii1. ~/rairie ~um~vil~e <br /> <br />Mailing Address <br /> <br />ior 97325 <br /> <br />City, State, 'Zip Code <br /> <br />SectiOn Twp__. Rge, <br /> <br />Tax Lot or Account # <br /> <br />Lot Size 3.61 acres <br /> <br /> 8856 Jeanne Ct. SM <br /> <br />Site Evaluation serial N~mber <br /> <br />Installer~s Na~e <br /> <br />B. G~NF~RAL DESCRIPTION <br /> <br /> x <br />New Construction Repair <br /> <br />Installation will serve: House x Mobile Home <br />Commercial Buildtng~Other (explain) <br /> <br />N~unber of Living Units 1 <br /> <br />Water Supply: Public __Community__ <br /> <br />__Mobile Home Park ........ <br /> <br /> 4 <br /> Number of Bedrooms <br /> <br />Private x Garbage Disposal? yes <br /> <br />Proposed Snhsarface Sewage Disposal System Plot <br /> <br />2. Planning Evaluation -- Building Permit <br /> <br />3. Building Plans <br /> <br />to the best of my knowledge a~d belief. <br /> <br />Permit No. ? <br /> <br />EH-57 rev. 12/76 <br /> <br />Signature <br /> <br /> <br />