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,,- ~ Set# 6-78~6 <br /> <br /> D2FAKT~NT OF ENVI~O~NT~ QU&LIIY <br /> <br /> STATE~NT OF FE ~SURFACE SEWAGE DISPOSe, <br /> <br />M~rion County Health Depar: ~ Non-ref~dable $37.50 per lot <br />3180 Cen~er St. NE, Roo~ 2~ /~ ~ to be submitted with <br /> <br />DESCRIPTION OF P~CEL (Attm ~ <br /> <br /> Sea,ion ~ ~ To~mh~p ~ Range /~ , Cowry of~,-~ , Oregon; tax lot/~ <br /> Narrative Description; ~/~~ ~ ~ ~,~-~ ~l~ ~ ~ ~ <br /> <br />P~OPOgED USE OF PARCEL (NU~R OF BO~gZ~E$} ~D LOT SIZe(g)r <br /> <br /> If for a commercial business or restaurant~ we need to know the number of employees and./ <br /> or the seating capacity: <br />F~SENTLY DESIGNATED LAND USE~ ~ON~_q~NG A~D NAM~ OF DES%GNATING AGENCY: ~ ~('..~- <br /> <br />TEST HOLE REQUIREMZNTS: <br />One Homesite: You will not need to dig test holes unless notified. <br />AWe or More Homesites: Two test holes must be prepared on each parcel, 2 ft. by 3 ft. wide <br /> and ~ft. deep, and 75 ft. apart in the <br /> proposed <br /> areas. <br /> Test~'holes (~have been prepared ( ) will be prepared by ~ -~ ~-~ 7~ <br /> (date) <br />THIS REPORT 1~ NOT A PERMIT. It does not eliminate the need for required planning commis- <br />sloo approval, bet]ding, or location permits. <br /> <br />i BEREBY REQUEST FRON %~E DEPARTMENT OF ENVIRONMENTAL QUALITY A STATEMENT OF FEASIBILITY <br />Name of Applicant /~'~ ~/, ~'~lF Signature o~ Applican <br /> <br />Address of Applicant ,~4 ~q~ge?_~.J~ Tit O~er, Buyer, A~t <br />C~y, State, Zip Code~ ~a~ ~d~' Date ~'-2~-Y~ <br /> ******************************************************************************************* <br /> (for DEQ or Agent use only) ~/~/~ ~ <br /> <br />Comments and recommendations based on Subsurface Site Investigation by DEQ or Contract Age' <br /> <br />Soil is similar to Nekia silty clay loam. <br /> <br />Approved pending construction permit applications. <br /> <br />"Pre~en~ lhis eval~:4ion whqn applying <br />5uildmw pormits P~os ~or ~u~' q,Jual 1Ora, <br />that are approved,~oy~e.app}~ tO permit <br /> <br /> Statement of DEQ/Contract Agent Relative to Above Application <br />(~Th¢ above described method of sewage disposal is ap~v~d subject to the following <br /> conditions: <br /> <br />( ) The above described method of sewage disposal is not approved for the follow~ng reasor <br /> <br />For tho DgQ/Contraet Agent;, o . ~ate f-7 <br /> <br /> <br />