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Depart~en~ off Environmental Qual£ty~.~ O~EGC~ ~7~ - ~-~S <br />12~4 S~ W. Mo~rison <br />POrtland, Oregon 97205 <br /> <br />Land Quality <br />County <br /> <br /> Application to the Department of Environmental Q~ality <br /> <br /> for a Permit to ~Cq.nstruc..t a <br /> New or Red, air a Subsurface Sewage <br /> <br /> Disposal System <br /> <br /> Permit Pees; Ne~w "' ~el0air, Alteration $15.0~ <br /> $~i00 ($25.00 wi%h ~ite evaluation) <br /> <br />RE~ER~NCE INFORMATION <br /> <br />_?3oyd Ch~u]_cs Bizlc~:s <br />N~me of Applicant <br /> <br />Address <br /> <br />Aumsville <br /> <br />City <br /> <br />B. GENERAL DESCRIPTION <br /> <br />Tax Lot or Account # <br />L0~ size 16 acres <br />LOcation Rt. 1~ <br /> <br />New Construction X <br /> <br />Installation will serve: <br /> <br />Co~ercial Building. <br /> <br />No. of Living Units 1 <br /> <br />Water Supply: ~ublic <br /> <br />Other (Explain) <br /> <br />No. Bedrooms 3 <br />Cc~nunit~ <br /> <br />, Re~air <br /> <br /> Mobile Home <br /> <br />Private <br /> <br />X Mobile Home Park <br /> <br />X Garbage Disposal.? <br /> <br /> REQUIRED ,~XHIB~yS ,. r~O~ P'Jla~ ' <br /> 1. Proposed S~bsurface Sewage Disposal System [ <br /> <br />2. Planning Evaluation - ~uilding Permit .(.Loc.al Option) ,, <br /> <br /> other (Local Option) Buildin~ 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 /> ,'- <br /> &~a~ure--fOwne~/~ns~a~I~) ...... <br />Permit NO. ~ ~ Da~e 6/4/74 <br />Date <br /> <br />InterimForm #1 <br /> <br /> <br />