Laserfiche WebLink
Environmental Health Services Division <br />Mario~ County Department of Public Health <br />Salem, Oregon 97301 (588-5346), agent for: <br />Department of Envirom~ental 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 Repair <br />a Subsurface Sewage DiSposal System <br /> <br />Permit Fees: New - $75.00 ($37.50 with site evaluation) <br /> <br />Repair~ R~llace~ Alteration - $25.00 <br /> <br />A. REFERENCE INFORMATION <br /> <br />Name o£ APpiieant ~ <br /> ~%. iT Vox 25 <br /> <br />Mailing Address <br /> <br />City, State, Zip Code <br /> <br />Section Twp Rge <br /> <br />Tax Lot or Account # <br /> <br />Lot Size 136 acres <br /> <br /> Rt. 1, ~ox 25, ~urora 9700~ <br />property ~dre~s -- <br /> <br />Site Evaluation Serial Number <br /> <br />GENERAL DESCRIPTION <br /> <br />Nam Construction <br /> <br />Installation will serve: House x <br /> <br />Commercial Building . Other (explain) <br /> <br />Number of Living Units <br /> <br />Water Supply: Public <br /> <br />R_~UIRED EX}~IBITS <br /> <br />1. <br /> <br />2. <br /> <br />3. <br /> <br />Installer'e Name <br /> <br /> Repair x <br /> <br />Mobile Home Mobile Home Park <br /> <br /> Repair drain - very old house <br /> <br />Number of Bedrooms <br /> <br />4 <br /> <br />__ Community __ Private __ Garbage Disposal? no <br /> <br />Proposed Subsurface Sewage Disposal System Plot P%an <br />Plaaning Evaluation -- Building Permit <br /> <br />Building Plane <br /> <br />I hereby certify that the information contained in this application ip true and correct <br />to the best of my knowledge and belief. ~ 4 ~-~ / <br /> <br />Issued s gn ture <br /> <br /> Date <br />rev. 12/76 <br /> <br /> <br />