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Department of Environmental Quality <br />1234 $. W. Morrison <br />Fortland, Oregon 97205 <br /> <br />R~u~ To: <br />~V~ON~ZNTA~ H£A~T~ SZaWC~ D~ON Land Quality <br />MARION COUNTY D~AR~NT OF PU~IQ ~L~ <br /> <br />Application to the Department of Environmental Quality <br /> <br /> for a Permit to Construct a <br /> <br /> New or ~ a Subsurface Sewage <br /> <br /> Disposal System <br /> <br /> Permit Fees: New~ <br />REFERENCE INFORMATION <br /> <br /> Repair, Alteration $15.00 <br />· 00 ($25.00 with site evaluation) <br /> <br />B. GENERAL DESCRIPTION <br /> <br /> Tax Lot or ~ecount # _ <br />Lo% size .............. /0 <br /> <br />New Construction <br /> <br />Installation will serve~ <br /> <br />Conunercial Building <br /> <br />No. of Living units <br /> <br />Water Supply= Public <br /> <br />Repa ir <br /> <br />House Mobile Home <br /> <br /> other (E~plain) <br /> <br /> No. Bedrooms ~ <br /> <br />~Mobile Home Park <br /> <br />Community,, <br /> <br />Private,,,,.~ Garbage Disposal? <br /> <br />C. .RE.QUIRED EXHIBITS <br /> <br />rl0t Plan <br /> <br />1. Proposed Subs~face Sewage Disposal Syst~ <br /> <br />2. Planning Evaluation - Building Permit~Local O~tign) <br /> other (Local Option) BuildinE Plans <br /> <br />I h~reby certify that the information contained in this application is true and <br />correct to the best of my knowledge and belief. <br /> <br />Permit No. <br /> <br /> Date <br /> <br />Signature (Owner/Installer) <br /> <br />Interim Form <br /> <br /> <br />