Laserfiche WebLink
Envirommental Health Services Diviaion <br />Mariom County Department of Public Health <br />Salem, Oregon 97301 (588-5346), agent for: <br />Department of Environmental 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 Q~ality <br /> for a Permit to C0nstruct a New o~'~ <br /> a Subsurface Sewage Disposal System <br /> <br />Permit Fees: New - $75,00 ($37.50 with site evaluation) <br /> <br />Repair~Replace~Al~r~t!on - 825.00 <br /> <br />R~FERENCE %NFORMATION <br /> <br />Name of Appllcan~ ~ <br /> <br />Mailing Address <br /> <br />City, State, Z~ip Code <br /> <br />Tax Lot or Account # <br /> <br />Lot Size ~51~-'' /~-' <br />Property Addre~ , /FZ¢~~ <br /> <br />Site Evaluation Serial N~mber <br /> <br />Installer' s Name <br /> <br />B. GENERAL DESCRIPTION <br /> <br />New Construction ~'~" <br /> <br />Installation will serve: House <br /> <br /> Repair <br /> <br />Mobile Home <br /> <br />Mobile Home Park <br /> <br />Co~nuercial Building <br /> <br />Number of Living Units <br /> <br />Water Supply: Public <br /> <br />__Other (explain) <br /> / Number of Bedrooms <br /> <br /> __ Co=nnunity__Private /~arbage Disposal? <br /> <br />1. Proposed Subsurface Sewage Disposal System Plot P%an <br /> <br />2. Planning Evaluation -- Building Permit <br /> <br />3. Building Plans <br /> <br />I hereby certify that the information contained in this application is true and correct <br /> <br />to the best of my knowledge and belief. <br /> <br />Permit No. <br /> <br />Issued <br /> <br />EH-57 rev. 12/76 <br /> <br />SignatUre <br /> <br />Date <br /> <br /> <br />