Laserfiche WebLink
En~mS Health Sc~-vice~ Divfsio~ <br />M~rion County Department of Public <br />~ale~, O~e/~n 97301 (585-53~_~), ~ent for: <br />~t of Environments3. ~li~y <br /> <br />To be submitted w~th application for <br />building permit or ~a~bile home place- <br />ment pernzit. <br /> <br />Permit Fac-s: N~_ - $50,00 ($25.00 wit~ site evaluation) <br /> <br /> I~tr ~/Zar~tion - $15.00 <br /> <br />Tax Lot or Account # <br /> <br />New CollStruction <br /> <br /> Installation will serve: <br /> <br />Cc~merci~ Buildins <br /> <br />Number of Living Units <br /> <br />Water Supply: Public, <br /> <br />Hous~ 51~bila 5me ~---' Mobile }b~ Pa~k <br /> <br />,,, Oth~ (explain) <br /> <br />Bkmber of Bc~roc~r~ ~-~ <br /> <br />C~a~nity ~ Private <br /> <br />Garb~g~ Disposal? <br /> <br />1, Prolx~ed Subsurface S~wva~e Disposal Sy.~t~n Plot Plan <br /> Pl~uning Evaluation ~ BuildinE Pernlit <br /> <br />2. Buil~ Plaus <br /> <br />I horeby ¢x~.rtify ~hat the infor~lZlon contained in this ~licati¢~ is trio and corr£~t <br />to the !~ of my knowledg~ add be].ie£. <br /> <br />Signature (c~v~er/i~taller) <br /> <br />7/74 Date ......... <br /> <br /> <br />