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E~virommental Healt~h Services Division <br />Nario~ County D~0a~-~nt Of P~bli¢ Eeal~h <br />~lem, 0regom ~01 (S~-S~46), $~ for: <br />~~ of E~viro~tzl ~ity <br /> <br />TO be submiSted with application for <br />building pe~$ or moDile home place- <br />ment p~-mit. <br /> <br />Application tx; J~he DePa~Y~n~ o~ Environmental Q~it~ <br /> for a Permit ~o Construct a New or <br /> a S~a~face S~wage DisposaX Sysmem <br /> <br />Permit Fee~: N..e,w - $50.00 ($25.00 with site evaluation) <br /> <br />~, ~tera~n- $~.~ <br /> <br />8~ction. 11 T 4 S R1 W W.M. <br /> <br />Tax )Lot Or Account # ...... <br /> <br />Eot Size .%0,000.se ft. <br /> Lot 4, ~lk 12 <br /> <br />~p~y <br /> <br /> JO~ W~i%e <br /> <br />Installation will <br /> <br />Nobile t:k:/nG, ,X ~obile Hame Park__.._._____ <br /> <br />C~rcial Building ~ Other (e~ola~l) ... <br /> <br />Number of Living Units <br /> <br />Water ~%zpply: Public.,. Coat. miry <br /> <br /> N~r of t~tro¢~ .. 5 <br /> <br />x Private Garbage Disposal? x <br /> <br />1. ~ Sttb~Jrface Sewag~ Disposal Syst~n Plo~ Plan <br />2. Pl~nnin~ ~v-~lu~zio~ -- ]~u~l~p_~ ~ <br /> <br />3. f~Ailding Pl~us <br /> <br />I h~reby certify that the inforn~tion CO~taJ~u~d ~n this appIica$io~ is ILr~e a~ ~t <br />to the best of my knowledge and belief, <br /> <br />7174 <br /> <br /> <br />