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Environmental Health Services Division <br />M~rion County Department of Public Health <br />Salem, Oregon 97301 (588-5346), agent for: <br />Department of Envirormantal Quality <br /> <br />To be submitted with application for <br />building permit or mobile home place- <br />ment permit. <br /> <br />Application to the Department of Environmental Qt~ality <br /> for a Permit to Construct a New or Repair <br /> a Subsurfaae Sewage Disposal System <br /> <br />Permit Fees: New - $75.00 ($37.50 with site evaluation) <br /> <br />Repair~ Replace, Alteration w $25.00 <br /> <br />A, REFERENCE INFOP-MATION <br /> <br /> viola Korkow <br /> <br />Name of Applicant <br /> <br /> 8223 Wes% Stayton kid. <br />Mailing Address <br /> <br /> :,ums~ille <br /> <br />City, State~ Zip Code <br /> <br />Site Evaluation Serial Number <br /> <br />Section_ <br /> <br />Tax Lot or Account # <br /> ~ acres <br />Lot Size <br /> <br /> 9223 ~est ~tayto~ ~<d, .~umsvi]le <br /> <br />Property Address <br /> <br />Installer's Name <br /> <br />GENERAL DESCRIPTION <br /> <br />New Construction <br /> <br />Repair <br /> <br />Installation will serve: House <br /> <br />Mobile Home x Mobile Home Park <br /> <br />Commercial Building <br /> <br />· Other (explain) <br /> <br />Replace <br /> <br />Number of Living Units <br /> <br />Number of Bedrooms <br /> <br />3 bedroom <br /> <br />Water Supply: Public __ Community __ Private__ Garbage Disposal? no <br /> <br />1. Proposed Subsurface Sewage Disposal System Plot Plan <br /> <br />2. Planning Evaluation -- Building Permit <br /> <br />3. Building Plans <br /> <br />to the best of my knowledge and belief. <br /> <br />Zssued 7 <br /> <br />hereby certify that the inforraation contained in this application is true and correct <br /> <br /> $igrfat'ure / ...... <br /> <br /> ,, <br /> Date ~ <br /> <br />5t{-57 rev. 12/76 <br /> <br /> <br />