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Depar~,ent of Environmental Quality <br />1234 $. w. Morrison <br />Portland, Oregon 97205 <br /> <br />~e~um To: <br /> <br />;{&RION COUNTY D~A~TMEN~ OF ~U~M~ H~/A~{ Land ~ality <br /> <br />~ o~N S~OI. ~S-~3~ County <br /> <br />Application to the Department of Environmental Quality <br /> <br /> for & Permit to Construct a <br /> <br /> New or ~ a Subsurface Sewage <br /> <br /> Disposal System <br /> <br /> Permit Fees: <br />REFERENCE INFORMATION <br /> <br />New Repair, Alteration $15.00 <br /> $50.00 ($25.00 with site <br /> <br />~ame ~o f Applicant <br /> <br />Address <br /> <br />City <br /> <br />TaX Lot or Account <br /> <br />B. GENERAL DESCRIPTION <br /> <br />New Construction <br /> <br />Installation will serve= <br /> <br />Commercial Building <br /> <br />No. of Living Units <br /> <br />Water Supply: Public <br /> <br />/ Repair <br />House Mobile Home <br /> <br /> Other (Explain) <br /> No. Bedrooms ~ <br /> COn~nunit~ Private <br /> <br />Mobile Home Park <br /> <br />/Garbage Disposal~/~Ld) <br /> <br />C. REQUIRED EXHIBITS <br /> <br /> Plot Pi~ <br />1. Proposed Subsurface Sewage Disposal Syst~~ <br /> <br />2. Planning Evaluation - Building Permit (Local Option) <br /> <br />3. Other (/~cal Option) Building Plans <br /> <br />I hereby certify that the information contained in this application~ true and <br />correct to the best of my knowledge and belief.~ /f~.. <br /> ~ /~_~ ,.~..~..-~-~" <br /> ~nature (Owner/Inst.~ler)7" <br /> <br /> Date <br /> <br />Interim Form <br /> <br /> <br />