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Environmental Health Services Division <br />Marion County Department of P~Iic Meal, th <br />Salem, Oregon 97301 (588-5346), agent for: <br />Department of Environmental Quality <br /> <br />To 'be submitted wf%h application for <br />building permit or mobile home place- <br />ment <br /> <br />Application ~o the Department of Environmental Quality <br /> for a Permit tocon~s.~,ruet a New or'~e~a,ir <br /> a Subsurface gewage Disposal System <br /> <br />Permit Fees: N__e~ - $75.00 ($37.50 with si%e evaluation) <br /> <br />_RpPalr,'~eplace;A1A,9~ation - $25.00 <br /> <br />REFERENCE iNFORMAT ION <br /> <br /> Section Twp <br />Name of Applicant <br /> <br />Mailing Address <br /> <br />Cif~, State~ Zip Code <br /> <br />Sire Eval~atio~ Serial <br /> <br />B. GENERAL DESCRIPTION <br /> <br />Installation will serve: House <br /> <br /> Repair .............................. <br /> <br />~Mobile ~ome .... Mobile Home. Park ....... <br /> <br />Commercial Building----Other (explain) <br /> <br />Number of Living Units ~ _~/ Number of Bedrooms _-?~ <br /> <br />Weter Supply: Public ....... Community ~ Private ~/' <br /> <br />c, R_E~)IRED EXHlS~T$ <br /> <br />Garbage Dispo~ai?~-.- '. <br /> <br />].. Proposed Subsurface Sewage Disposal System Plot P~an <br /> <br />2. Planning Evaluation -- Building Permit <br /> <br />3. Building Plans <br /> <br />I hereby certify that the information contained in this application and correct <br />to the bea~ of my knowledge and belief. ~ [(-/ ~ is true <br /> <br /> Signature <br />issued /.. , <br /> <br /> Date <br />~I-57 rev. 12/76 <br /> <br /> <br />