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F~vir~0~ ~ntal ~ealth Ser~vi~e~ ~ivtsion <br />?,', '. % ".~n~y Departmen~ o~' ~ ~bllc Health <br />~ "':,, Oreg~ 97301 (588-53A6), agent for: <br />Dz~art~ of ~nvironmenta.1 Q~li~y <br /> <br />To be submi=ced with appl~¢ation for <br />building permit o~ mobile home place- <br />ment p~:i~. <br /> <br />Application to the Department of EnvirommentaI Quality <br />for a Fer~it to ~o~truc~ a New or ~mpa!~ <br />a Subsurface Sewage Disposal System <br /> <br />Permit Fees: New - $75.00 ($37,50 with site evaluation) <br /> <br />R~epaSr.~Re~lac¢,:Altera=tom - $25.00 <br /> <br />Name of Applicant <br /> 17'q15 ~l~l~-,~', dr. ~L <br /> <br />Z~l~ng A~'a~&~,~ ..... <br /> Aum~$vi [le <br /> <br />City, State, Zip C0d~ <br /> <br />Site E~alua~ion Serial Number <br /> <br />Section -- <br /> <br />LOt Size ll& scrc~_ <br /> <br />Property Address <br /> <br /> B. ~el~n <br />I~allsr's Name <br /> <br />g, EENgK~J~_pESCRIPTION <br /> <br />lnstallstton will serve: <br /> <br />Mobile Rome x MobiLe t~ome Park <br /> <br />Cez~mer¢ial Building ___. <br /> <br />O~her (e~c~lain) ~ <br /> <br />Number of Living Units ...... <br />Water Supply: Public <br /> <br />__ Community_ <br /> <br />__ Number of Bedrooms 4 <br /> <br />........ Garbage Disposal? <br /> <br />C. ~[RED EYC~IBITS <br /> <br />Proposed Subsurface Sewage Disposal System Plot Plan <br /> <br />2. Planning Evaluation -- Building Pe~it <br /> <br />3. BuiJ.d%ng Pla~s <br /> <br />I kereby certify that the information contained in this application ie true and correct <br /> <br />~o tbs best of my knowledge and belief. <br /> <br />Permit No, ,~ :~ <br /> <br />EH-57 rev. I2/76 <br /> <br /> <br />