Laserfiche WebLink
Environmental Health Services Division <br />~rion County 'Dep~cment of Public Health <br />Salem, Oregon 97301 (58~-5346), a~ent for: <br />Department of Environmental Qu~tity <br /> <br />To be submitted with application for <br />building pern,~[t or mobile hcme place- <br />meat permit. <br /> <br /> Application to the Department of Environmental Quality <br /> for a Permit to Construct a Now or Repair <br /> a Substtrfane Sewage Di.~possd System <br /> ff.~.(~$i5.~? with evaluation) <br />Permit Fees: Ne~_vi - $50.00 ~ .... site <br /> <br /> Ropair~ Alteration - $15.00 <br /> <br />A. ~ER~CE INFORNATION <br /> <br />City, State, Zip Code <br /> <br />Tax Lot or Account # <br /> <br />Property Address <br /> <br />Installer's Name <br /> <br />B. GENEPJ~L DESCRIPTION <br /> <br />New Construction <br /> <br />Installation will serve: <br /> <br />House <br /> <br />Repair <br />[,,~obile Ho~e <br /> <br />~obile Home Park <br /> <br />Ccernercial Building __ Othar (e~plain) <br /> <br />Number of Living Units / Ntunber of Bedrooms <br /> <br />Water Supply: Public__Ccm~amity ..... Private >~ C~rb~ge Disposal? <br /> <br />1. Proposed Subsurface Sewage Disposal Systen Plot Plan <br /> <br />2, Planning h~galuation -- Building Pemit <br /> <br />3. Building Plans <br /> <br />I hereby certify that the information contained in this application is true and correct <br /> <br />to the best of my knowledge ~nd belief. <br /> <br />pe t No. <br /> <br />EH-57 7/74 <br /> <br /> (owner~in~2~i6r ~ <br /> <br />I~te <br /> <br /> <br />