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Environmental tlealth Services DivisiOn <br />Marien ~ounty Department of Pt~lic~Mealth <br />Ss~em, Oragen 97301 (588-5346), agent for: <br />Department of Environmental Quality <br /> <br />1o be submitted with application for <br />bnl~dtng permit or mobile home place- <br />meet permit. <br /> <br />Application to the Department of Environmental Quality <br />for a Permit to Construct a New o~ Re--ir <br />a Subsurface Sewa8e Disposal System <br /> <br />Permit Fees: New ~ ~ (~with site evaluation) <br /> <br /> R~iy, Rcp3ace, Al~te'ratton - $25.00 <br /> <br />RI~EREN¢ L INFORMATION <br /> <br />Mailing Address <br /> .. <br /> <br />Site Evaluation Serial Number <br /> <br />Section ~, Twp R§~ <br /> <br />Tax Lot or Account <br /> <br />Lot <br /> <br />Pr~erey Address <br /> <br />B. GENERAL DESCRIPTION <br /> <br />Repair. <br /> <br />Installation will serve: House ...... Mobile Home ~-.. Mobile Mome <br /> <br />Commercial guildtng__~ Otber (explain) <br /> <br />Nomber o~ Living Units ..... ~ ~Nember of Bedrooms <br /> <br />Water Supply: Public ...... Community /PriVate Garbage D~pose~? <br /> <br />C. RE__~IRED EXRIBITS <br /> <br />Proposed Subsurface Sewsge Disposal System Plot P%an <br />Planniog Ewlluatton ~ Building Permit <br /> <br />Building Plans <br /> <br />Perm/t No. <br />Issued <br /> <br /> hereby certify that the information coetained in this epplicatiou iS true and corree~ <br />to the best of my knowledge al~d beiief. <br /> <br /> Signature <br /> <br /> Date <br /> <br />~t-57 rev. 12/76 <br /> <br /> <br />