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liarlon Co~ty D~partment of l~bltc Health <br />Salem, Oregon 97301 (58g-5346), agent for: <br />Department of Environmental Quality <br /> <br />building permit or mobile home place- <br /> <br />Application to the Department Of Environmental Quality <br /> for a Pex~v/t to'COnstt~ct a New o~'~ <br /> a S~bsurface Sewage Disposal System <br /> <br />Permit Fees: ~w - $?$,00 ($37.50 with Site evaluation) <br /> <br />RePair, Replace,? Altera~on ~ $25.00 <br /> <br /> Pmt~*idk R. NcGarvey <br />Name of Applicant <br /> <br />Rt. 2 Box 196 <br /> <br />Mailing Address <br /> Aurora, Or. 97002 <br /> <br />Code ....... <br /> <br />Tax Lot or Account ~ <br /> <br />Lo~ Size 18~ acre~ <br /> <br />New Cons=ruction <br /> <br />I~stallattouwill servel <br /> <br />N~mber of Livin8 Units _. <br /> <br />~ater Supply: Public__ Co--unity <br /> <br />Repair check <br /> <br />House'.___.Hobile Home' x Mobile ~ome Park <br /> <br />% Number of Bedrooms 2 <br /> <br />Private__Garbage Disposal? no <br /> <br />1. Proposed Subsurface Sewage DisPosal System Plot Plan <br /> <br />2. Plarmin~ Evaluation -- Butldim~ Permit <br /> <br />3. Ruilding Plans <br /> <br /> hereby certify thac the information contained in this application is true a~d correct <br />to the best of'my knowledge and belief. <br /> <br />Permit NO. ....~//~/ <br />Issued . ~'-~' ~.. <br /> <br />E~-57 rev. 12/76 <br /> <br /> <br />