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Enviro~nental Health Services Division <br />~¢arion Cotmty Dspartment of Public Health <br />Salem, C;£egon 97301 (588-5346), agent for: <br />Department of Environmental Quality <br /> <br />To be submitted with application for <br />building permit or ~obile l~om~ place- <br />ment pe~luit. <br /> <br /> Application to the Depar~nent of Environ~ental Q~ality <br /> for a Permit to Construct a New or P~ <br /> a Subsurface Sewage Disposal Syste~ <br /> <br />Permit Fe~s: N__~! - $50.O0~0~..with sit~ evaluation)~ <br /> Repairs. Alteration ~ $15.00 <br /> <br />City, State, Zip Code <br /> <br />Section /~ <br /> <br />Tax Lot or Account <br />Lot Size ~, <br /> <br />T <br /> <br />Property Address <br />Inetai]_er's ' ,.'-Y" <br /> <br />) <br /> <br />B. CeJNA~iL DESCRI~ri©N <br /> <br />New Construction <br /> <br />Repair <br /> <br />Installation will serve: House <br /> <br />Mobile H~mec~ 5~obile tIome Park <br /> <br />Commercial Building <br /> <br />Number of Living Units <br /> <br />Water Supply: Public <br /> <br />Other (explain) <br /> <br />Ccramunity <br /> <br />Private / Garbage Disposal? <br /> <br />C, R3kQ, UIRED EXHIBITS <br /> <br />l. ProDosed Subsurface Sewage Disposal SystamPlot Plan <br />2. Planning'Evaluation -- Building Pemit <br /> <br />3. Building Plans <br /> <br />I hereby certify t~t the information contained in this application is true and correct <br />to the best of my knowledge and belief. <br /> <br />Permit No. O~l't~ <br /> <br />EH-57 7/'/4 <br /> <br />tur~ (6wn6~/in~t aller~_~ <br /> <br /> <br />