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~alt~, O~e~o~ 97301 (588-53~6), a~en~ <br />D~par~nt of ~vi~utal <br /> <br />To be submitted with application for <br />building peri,it or mobile home place- <br />meat peraif. <br /> <br />Applicatiom to the Department O~ ~nvironmental Quality <br />for a Permit co ~pnstruct a New or?epa~r <br /> <br />Pe~ml; Fees: ~ - ~75.00 ($37.50 with elto evaluation) <br /> <br />Repa!~, P~ac~ Alteration - $25.00 <br /> <br /> Dwight Rebut <br />'Nome ~ tpplicant ............. <br /> <br />~ec~ion . ~1 ~p 4 ~e ]w <br /> <br />PO ~x 3500 <br />~'~kng Address' <br /> <br />PortlandxR~£xx Or. 97R~08 <br /> <br />Tax Lot or Accott~t ~ 40857-001 <br /> <br />Lot Size -- ~6 acres <br /> <br /> R%. 1 BOX 248 <br />Property A~dr~$s <br /> <br />Aurora <br /> <br />Sl~e Evalusti~fl~¥ial Number <br /> <br />inataller'$ Name <br /> <br />Installation will serve: <br />COmmercial Butldi~ .. <br />Number of Living Units <br />Water Supply: Public <br />REQUIR~ EXHIBITS <br /> <br />Repair <br /> <br />~on~e <br /> <br />Other (explain) <br /> <br /> Community ,.. <br /> <br />Rome ._w~__Mobile Ho~ Park ,, <br /> <br /> Nlaaber2of Be~ooms -- 2 + 3~ ~6~ ~ ~ ~t <br /> <br />· Prtvate x..x.~_ ~arbage Di~po~l? no <br /> <br />1. Proposed Subsurface Sewage Disposal System Plot Plan <br /> <br />2. Planning ~valuafion -- Building Pelm~it <br /> <br />3- BuiLding Plane <br /> <br /> I hereby certify that the information contained in t]~i~ application is true and correct <br /> ~0 the best of my knowledge and belief. <br /> <br /> ......... / <br />~-57 row, 12/76 ~ / ' <br /> <br /> <br />