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Environmental Health Services Division <br />Marion County Department of Pa~iic Beslth <br />Salem, Oregon 97301 (588-5346), agent for: <br />Department of Envirommental Quality <br /> <br />To be submitted with application for <br />building permit or mobile home place- <br />ment permit. <br /> <br />Application to the Department of Environmental Quality <br /> for a Permit to Construct a New or ~ <br /> a Subsurface Sewage Disposal System <br /> <br />Permit Fees: N__e~ - $75.00 ($37.50 with site evaluation) <br /> <br />Repair, Replaee~ Alteration - $25,00 <br /> <br />REFERENCE INFORMATION <br /> <br />~e of Applicant <br /> <br />Mailing Address <br /> <br />City, State, Zip Code <br /> <br />Tax Lot or Acceumt # , \S~7S-\~)q <br /> <br />Let Size__~ dl~ · <br /> <br />Property Address <br /> <br />Site Evaluation Serial Number <br /> <br />installer's Nam~ <br /> <br />~ENERAL DESCRIptION <br />New Con~truction __.~ <br />  <br />pafr <br />Installation will serve: Heuse/__~__Mobile Home__ <br /> <br />Mobile Home Park <br /> <br />Commercial Building~ <br /> <br />Number of Living Units <br /> <br />Water Supply: Public <br /> <br />~UIRED EXHIBITS <br /> <br />Other (explain) <br />/ Number of Bedrooms __. ~ <br /> Commumity~ Private .~Garbage Disposal? <br /> <br />1. Proposed Subsurface Sewage Disposal System Plot P!a~ <br /> <br />2, Planning Evaluation -- Building Permit <br /> <br />Building Plans <br /> <br />i hereby certify that the info~mation contained in this application is true and correct <br />to the best of my knowledge and belief. <br /> <br /> Signature <br />Issued <br /> <br /> Date <br />rev, 12/76 <br /> <br /> <br />