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Favironmental Health Set"cite8 Division <br />Marion Couuty ~par~men~ of ~12c Hca%th <br />Salem, Oregon 97301 (588-5~6), a~enC for: <br /> <br />To be submitted with application for <br />building perm/C or mobile home place- <br />ment permit. <br /> <br />Application to the Department of ~nvirom~ental Quality <br />for a Pe~ui~ to Cg, ns~ruct · N~ or ~pair <br />a Subsurfac~ S~age Disuse1 ~ys~em <br /> <br />Permit Pee~i ~ew - $75.00 ($37.~0 with site evaluation) <br /> <br />Re~air, Re~.~a~e~ Alteration - $25.00 <br /> <br />REFIgRENCE INFORHATION <br /> <br />Nam~ o p~i ~ ' <br /> <br />Mailing Addre$= <br /> <br />C~y, 8tate~ Zip Code <br /> <br />Site ~valuation Serial '~ber <br /> <br />Tax ~oc or Aeeounia t~ <br /> <br />OI!:~I~RAL D~SCRIPTION <br />New Construct/on ..V/ <br /> <br />Installation will serve: <br /> <br />Repair <br /> <br />Com~ercial Buildt~ ... <br /> <br />Supply: Public .... <br /> <br />Hous% 9/ Mobile Home <br /> <br />Mobile Hom~ Park <br /> <br />.. O:her (explain) <br /> <br /> / .... .. N~ber of Bedrooms _~ <br /> Com~unlty__Private ~/Garbage Disposal? IJ~._-~, <br /> <br />Proposed Subsurface Sewage DispOSal Syst~ Plot P!an <br />Plarmln8 ~valuation -- Build/rig Pe~: <br /> <br />3. Building Plans <br /> <br />rev. 12/76 <br /> <br />to the beat of my knowledge and belief, <br /> <br /> Signature / <br /> <br /> <br />