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Environmental Health Services Division <br />~rion County Departm~mt of Public Health <br />Salon, Oregon 97301 (588~5346), agent for: <br />Department of Environmental Q~m. lity <br /> <br />TO be ~.~tted with application for <br />building perr~t or mobile home place- <br />ment permit. <br /> <br /> Application to the Departn~nt of Envirommental C~ality <br /> £or a Per. it to Construct a N~ or <br /> a Subsurface Sewage Dis <br /> <br />Permit . ___ . <br /> Fces' New - $50 00 $25 00 with site evaluation) ' <br /> <br /> R~ air Alteration - $15.00 <br /> <br /> RITFi~C~E INFORMATION <br /> <br />'~an~ of Applic~t <br /> <br /> City~ State, Zip ~ <br /> <br />Section <br /> <br />Tax lot or Account <br /> <br />Property Address <br />Install~' s N~me <br /> <br />B. ~R_aL DESCRIDTI(XY <br /> <br />N¢fv Construction ~/ <br />Installation will serve: House <br /> <br />Repair <br />lfobile Hc~e <br /> <br />Cz~m~rcial Building~ Other (explain) __ <br /> / <br />Number of Living Units / <br /> <br />Water Supply: Public__ <br /> <br />Me, bile H~r~ Park <br /> <br />CasT. nit y __ <br /> <br />N~mfoer of Bc~droc~ms <br /> Private ~Garbage Disposal? __ <br /> <br />1. Proposed Subsurface S~vage Disposal System Plot Plan <br />2, Planning Evaluation ~- Building Permit <br /> <br />3, r~ilding Pt~ms <br /> <br />I hqreby certify t,l~t tl~ infoz~ation contained in ~his applicati~on is true and corr~c't <br /> <br />~--~ ?/74 ~.te ~ ~ <br /> <br /> <br />