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Environmental ttealth Services Divisibn <br />~rion County Department o£ Public Itealt~ <br />Salon, Oregon 97301 (588-5346), agent for: <br />Department of Environmental Quality <br /> <br />To be ~lbmitted with application for <br />building, permit or rrobile home place- <br />ment permit. <br /> <br />Application to the Departn'~3nt of Environmental Quality <br />for ~ Permit to Construct a New or Repair <br />a Subsurface sewage Di~sal System <br /> <br />Permit Fees: N~e~! - $50.00 ($25.00with sate evaluation) <br /> <br />Repair, Alteration - $15.00 <br /> <br />Lot or Account <br /> <br />Property Address <br />Installer' s Nmme <br /> <br />B1 ~ DESCRIPTION <br /> <br />New Construction <br /> <br />Repair <br /> <br />Installation will serve: t~l~- ~,~bileHca~__Nobile Home P~rk ..... <br /> <br />Cc~nercial Building .... Other (explain) <br /> <br />Number of Living Units / Number of ~ ~/ <br />Water Supply: Public Community Private ~. Garbage Disposal? <br /> <br />1. Proposed Subsurfaee S~wea~e Disposal System Plot Plan <br /> <br />2. Planning Evaluation -- Building Permit <br /> <br />3. Buildip~ Plans <br /> <br />I hereby certify that the information contained in this ~pplication is true and correcZ <br /> <br />to the best of ~y knc~-ledge and belief. <br /> <br /> <br />