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~nvir~z~en~ul }~ulth Se~ice$ Division <br />Marion County De~m~nt of ~ublic H~.!th <br />8alan, O~oA~a 97301 (5~3-53~6), a~e~z for: <br />De~t of R~vi~o;~tal Q%l~l±ty <br /> <br />To b. su~uit~ with applicat~c~ for <br />~uild~ permit or ~b~e ~ ~1~ <br /> <br />Pc~mi~ Yces: ~__~i - $~0.00 ($25.00 with site evs/uatlon) <br /> <br /> .Rc~t~ 5iteration - $15.0o <br /> <br />~sm~ Of A~licant <br /> <br />C£~ ', Stato, Zip Code <br /> <br />Section <br /> <br />L~stallatXon will s~e: House ~-/ Mobile ~ ~ ~{cbile ~ Park <br /> <br />Ccc~orcial Building __ Other (explain) ................... <br /> <br />Numbe~ of Living Units .... / .. Number of ~ ..... <br />Watcr ~ly: ~lic ~i~y .... ~i~to ~ ~b~e Di~? ~ <br /> <br />1. Proposed Subsurf~ce ~wa~e Di~l ~y~t~m~ Plot P!~m <br /> <br />2. Pl~nninK Ev21umtion -- ~uilding ~,rmit <br /> <br />3. Build/rig Plans <br /> <br />I hereby cx~.rtify that the information contained in this applic~a~ion is truo and correct <br />to ~ho ~st of my knowledg~ a~d beliof. <br /> <br /> <br />