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~nvironmental }{ealth Services Division <br />Mmrion County Department of Public Health <br />Salem, Oregon 97301 (588-$346), aKemt fo~: <br />Department of Environmental Quality <br /> <br />To be submitted with application for <br />b~i]d~ng permit or mobile home place- <br />menr permit, <br /> <br />Application to the Department of Environmental Q~altty <br /> for a Pez~it to Construct a New <br /> a Subsurface Sewage Disposa~ System <br /> <br />Permit Fees: ~e_w~ -~'""_~. ~with site evaluatJon) <br /> <br />~e~a~ir, Replace,__A~..t. er_ation - $25.00 <br /> <br />REFERENCE INFORMATION <br /> <br /> ___ <br />Mailing Address <br /> <br />City, State, Zip Co~ <br /> <br />Section ..... 1, ~_ Twp ~ Rge _~ ~ <br /> <br />Tax Lot or Account <br /> <br />Property Address~/ <br /> <br />Site Eva] ua t io~-~e~i~f ~umb er <br /> <br />GENERAL DESCRiPTiON <br /> <br />New Construction <br /> <br />Instal,la~ton will serve: <br /> <br />Installer' s N~me <br /> <br />House ?~ Mobile Home __ Mobile Home Park <br /> <br />Commercial Building <br /> <br />Number of Living Halts <br /> <br />Water Suppl~: P~lic <br /> <br />1. <br />2. <br />3, <br /> <br />__Other (explain) ..... <br /> <br /> , _Number of Bedrooms ~ <br /> <br /> ____ Community ,~ Private ,__Garbage Disposal? <br /> <br />Proposed Subsurface Sewage Disposal System Plot Plan <br /> <br />Planning Evaluation -- Bu~ld~ng Permit <br /> <br />Building Plans <br /> <br />Permit No. <br /> <br />I hereby certify that the information contained in this spplication is true and correct <br />to the best of my knowledge and belief. <br /> <br />EH-57 rev. 12/76 <br /> <br /> <br />