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Department of Enyironmental Quality' ~ :: "~:~ D'::A~KT~IL%~T O? I,~i~L~Q ~l¥~fl}~ <br />1234 $. W. Morrison - <br />Portland, Oregon 97205 <br /> <br />Land Quality <br />County <br /> <br />Application to the Department of Environmental Quality <br /> <br /> for a Permit to Construct a <br /> <br /> New or Re_~r_ a Subsurface Sewage <br /> <br /> Disposal syst~ <br /> <br /> Permit Fees: New $30,00 Re~air, Alteration $15.00 <br /> <br />A. P~FEP~ENCE INFOP/4AT ION <br /> <br />~ame of A~plicant ~ <br />city <br /> <br />B. GENERAL DESCRIPTION <br /> <br />Tax Lot or Account # <br /> <br />LOcation <br /> <br />Installers Name <br /> <br />New Construction <br /> <br />Installation will serve= <br /> <br />Co~ercial Buildin~ <br /> <br />NO. of Living Unite <br /> <br />Water Supply: Public <br /> <br /> Repair <br /> House__~L___Mobile Bo~e <br /> <br /> Other (Explain) <br /> <br />__~o. Bedrooms ~?/ <br /> Community Private__ <br /> <br />1. Proposed Subsurface Sewage Disposal System~ <br /> Planning Evaluation - Building Permit (Local Optigp) <br /> <br />3. Other (Local option) Buildin~ Plans <br /> <br />Mobile Ho~e Park <br /> <br />Garbage Disposal?~J~~ <br /> <br />I hereby certify that the information contained in this application is true and <br />correct to the best of my knowledge and belief, <br /> <br />Per-it NO. <br /> <br /> Date <br /> <br />Si~h~atur e ~6w~er~Installer ) <br />Date-- ,..~ <br /> <br />Interim <br /> <br /> <br />