Laserfiche WebLink
Environmental Health Servicea Division <br />Marion County Department of Public Health <br />Salem~ Oregon 97301 (588-5346), agent for: <br />Department of Environmental Quality <br /> <br />To be submitted with application for <br />building permit or mobile home place- <br />merit permit. <br /> <br />Application to the Department of Environmental Quality <br /> for a Permit to Construct a New or ~e~J~r <br /> a Subsurface Sewage Disposal System <br /> <br />Permit Fees: N. ew ~ $75.00 ($37.50 with site evaluation) <br /> <br />R__epair. Rep,s.ce, Alteration - $25.00 <br /> <br />A. REFERENCE INFORMATION <br /> <br />Ma i_jl~ lng Address <br /> <br />CSty, State, Zip Code <br /> <br />Site Evaluation Serial Number <br /> <br />Section ~ ? Twp <br /> <br />Tax Lot or Account # <br />Lot Size <br /> <br />S Rge f <br /> <br />Property Address <br /> <br />Installer' S Name <br /> <br />B. GENERAL DESCRIPTION <br /> <br />New Construction <br /> <br />Installation will serve: <br /> <br />Commercial Building <br /> <br />Number of Living Units <br /> <br />Water Supply: Public <br /> <br />REQUIRED E~iIBITS <br /> <br /> Repair <br />House ~/~ Mobile Home <br />Other (explain) <br /> <br /> / <br /> <br />Community__ <br /> <br /> Mobile Home Park <br /> <br />__ Number of Bedrooms <br /> Private :~/ Garbage Disposal? _~,~ <br /> <br />1, Proposed Subsurface Sewage Disposal System Plot Plan <br /> <br />2. Planning Evaluation -- Building Permit <br /> <br />3. Building P~ans <br /> <br />I hereby certify that the information contained in this application is true ~nd correct <br /> <br />to the best of my knowledge and belief. <br />Permit NO. ~ <br /> <br />EH-57 rev. 12/76 <br /> <br />Date / ' <br /> <br /> <br />