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Environmental Health Services Divis~on' <br />Marion County Dep~rt~nt of Public Health <br />Salem, oregon 97301 (585-53~6), agent <br />Dapartmeu~ of Eavirommental Quality <br /> <br />To be subwtt~e~ ~th applieatiou for <br />~utlai~g pa~tt or mobile home place- <br />men~ pe~t. <br /> <br />Application to the Depart~-~nt of Environmental Quality <br /> <br /> a Subsurface Sewage Disposal System <br /> <br />Pezmit Fees: ~e~ - $75,00 ($37.50 with site evaluatiou) <br /> <br />Repair,'Re~lacm; Alte~a~iom ~ $25.00 <br /> <br />Tax Lot or Account ~ <br /> si.., .}ooX <br /> <br />?~oper tY Adare~ .... <br /> <br />Site ~%~al~ation Serial Number <br /> <br />G~NEFU~ DESCl~Ip~ION / <br />New Con~truction ~, ~ .... <br /> <br />Installation ~1~ se~e/ <br /> <br />Co~ercial Buliding~ <br /> <br />Number of Living Units ., <br /> <br />Name <br /> <br /> Repair <br />Hous~'~bile Homi' <br /> <br />OCher (explain) <br /> /. <br /> <br />Water Supply; Public ~ Co~m~a~ity <br />.REQUIRED EXH I,BITS <br /> <br />· Mobile Home Park ........ <br /> <br /> N'~hOr of Bedrooms 3' <br />~rivate . Garbage Disposal? , <br /> <br />1. Proposed Subsurface Sewage Disposal System Plot <br /> <br />2. Planning Evaluation -- Building Permit <br /> <br />3. Building Plans <br /> <br /> hereby certify that the information ~ou~eined in this application ~ cr~e and ¢o~rec= <br />~o the best of'my knowleage and belie£. <br /> <br />Issued <br /> <br /> "' <br /> <br /> <br />