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A~PLIGA~ION~ TO Ser# 10-78-4 <br /> DEPART}~NT OF ENVIROIqMEMTAL QUALiIY <br /> <br />STATEMENT OF FF~S%BILITY"FOR PROPOSED SUBSI~RFACE SEWAGE DISPOSAL <br /> <br />FEE SCHEDULE: <br />Non-refundable $37.50 per lot <br />to be submitted with <br />application. <br /> <br />"RETUR/q TO: <br />Marion County Health Department <br />3180 Center St. NE, Room 220 <br /> Salem~ Oregon 97301 <br /> <br /> DESCRIPTION OF PARCEL (Attach Plot Plan as Exhibit A) <br /> <br /> Section f~ ; Townsh~,p ?£ ; Range /~/, ; C9~ty of ~r~ , Oregon; Tax lot <br /> <br /> P!IOPOSED USE OF PAR(~Ef'(~~HO~S!.%~.~.~D LO~ [S%~(p): _ <br /> <br /> if for a commercial business or restau~ant~ we need to kn~w the n~mber of employees and/' <br /> P~SgN~Y DESi~ATED L~D USE~ ~ONING, ~D N~ O~ DESI~ATtNG A~ENCY: <br /> <br /> TEST ~{OLE REQUIRE~TS. <br /> One Hol~site: You will not need to dig test holes ~les$ notified. <br /> '~o or More ~omesites: ~o test holes must be prepared op each parcel, 2 ft. by 3 ft. wide <br /> and 4 ft, deep, and 75 ft. apart in the proposed area~. <br /> Tes~ holes ( ) have been prepared ( ) will be prepared by __ <br /> <br /> TH..[S REPORT IS NOT A PERMIT. It does not eliminate the need for required planning <br /> sion approval, building, or location permits. <br /> <br /> I HEREBY REQUEST FROM THE DEPARTM~T OF ENV%RON~NT~ QU~I~ A STATE~NT OF F~SIBILITY OF <br /> THE ~OVE ME%~OD OF SEWAGE DISPO~ FOR '~E ~OVE DESCRIBED P~CEL. <br /> ~ame o~ ~pg~eanr $~~ 8~gna~ure of ~pplSean~t~{ <br /> 115 8~ ~ ~{'~ '~'(~ Title O~e.r~...' B~r,(Agen~ <br /> Add~ .~ss of Applicant <br /> <br /> (for DEQ or Agent use only) <br /> <br /> Co~ents add ~ icommendations based on S~Dgurface Site %nvestigation by DEQ or Contract Agen <br /> <br />~g~nt Signature Date <br /> <br /> Statement of DEQ/Contract Agent Relative to Above Application <br /> <br />( ) ~e above described method of sewage disposal is approved subject to the following <br /> conditions: <br /> <br /> ( ) ~%e above described method of sewage disposal ia not approved for the following reasoss <br /> <br />For the DEQ/Contract Agent: <br /> <br />Date <br /> <br />EH-50 Rev. 11/76 <br /> <br /> <br />