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Environmental ~Iealrh Services Division <br />~lrion County Depart~,ent of Public Health <br />,~al~, ~:egon 97301 (588-5346), agent for: <br />De~ortment of Environmental Quality <br /> <br />To be subraitted with application for <br />building permit or mobile home place- <br />me.ut permit. <br /> <br />Application to the Department of Envirormaental Quality <br />for a Permit to Construct a New or Repai~ <br />a Subsurface Sewage Di~posal System <br /> <br />Permit Fees: <br /> <br />Ncw~- $50.00 ($25.00 with site evaluation) <br /> <br />Rt~pair~ Alteration - $15.00 <br /> <br />A. RE~L~CE INF~TION <br /> <br /> Ronald ^. JEE <br />~m.~ of Applicant <br /> <br /> 42 Willow Island~ <br />Maili~ Address <br /> <br />Canby, O~ 97013 <br />City, State, Zip Code <br /> <br />Section ,, 21 <br /> <br />T 4 R lw <br /> <br />~ Lot or Account # <br /> <br />Lot Si~ 4.57 acres <br /> <br />Property Address <br />Installer' s Name <br /> <br />B. C~P~ERAL DESCRiPTI@~ <br /> <br />New Construction <br /> <br />Installation will serve: <br /> <br />Co~£rcial Building <br /> <br />Number of Living Un~ts <br /> <br />Water Supply: Public <br /> <br /> x Repair <br /> tbUse Mobile Home <br /> <br />Other (explain) <br /> <br />Cc~mmity <br /> <br />x ~k~,bile Home P~k <br /> <br />Number of Bedrooms 3 <br /> <br /> Private Garbage Disposal? <br /> <br />yes <br /> <br />C. R/~3IREDEXHIBITS <br /> <br />1. ProDosed Subsarface $~age Disposal Sy~t~n Plot Plan <br /> <br />2. Planniag Evaluation -- Buildiag Permit <br /> <br />3. Buildi~ Plans <br /> <br />I hereby ~ertify that .~tho information contained in this ~pplication is true and correct <br />to th~ best of my knowledge and belief. <br /> <br /> ~ -- ~g~fatur e z< oy~r/~st al ler ) <br /> <br />m -57 7/74 <br /> <br />D~e <br /> <br /> <br />