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Re~n To; <br /> E~rV~ON~;RTAL HEALTH SBRVIc:~5 DIV~ION <br />Depar~t of ~viro~en~l ~ality MARION COU~Y D~AR~ ~ PUBIC H~LTH L~d ~ality <br /> 24~ FRAN~ ST~, <br />1234 S. W. Morrison s~ O~GON 97~01 · 588.5348 County <br />Portland, Oregon 97205 <br /> <br /> Application to the Department of Environmental Quality <br /> <br /> for a Permit to Construct a <br /> <br /> New or ~air a Subsurface Sewage <br /> <br /> Disposal System <br /> Permit FeeS: New{ ; Re,air, Alteration $15.00 <br /> $50.00 ($25.00 with site evaluation) <br />REFEP~NCE INFORMATION <br /> <br />~ame ~of Applicant <br /> <br />City <br /> <br />Section T R <br /> <br />Tax Lot or Account <br />Lot size <br /> <br />LOcation <br /> <br />Installers Name <br /> <br />B. GENERAL DESCRIPTION ...... <br /> <br />New Construction ........ ,,~ <br /> <br />Repair <br /> <br />Installation will serve: House_~Mobile Hoale <br /> <br />Mobile Some Park <br /> <br />Cormuercial Buildin~ <br /> <br />No. of Living units <br /> <br />Water Supply: Public <br /> <br />Other (Explain) <br /> <br />No. Bedronms 3 <br /> <br />Community Private X Garbage Disposal? <br /> <br />REQUIRED EXHIBITS <br /> <br />1. Proposed subsurface Sewage Disposal Systeml <br /> <br />Plan <br /> <br />2. Planning Evaluation - Building Permit (Local Option) <br /> <br />3. Other (Local Option) B~ildin$ Plans <br /> <br />I hereby certify that the information contained in this application is true and <br />~orrect to the best of my knowledge and belief. <br /> <br />Permit No. __~uL~____- <br /> Date <br />Interim Form $1 <br /> <br />Date <br /> <br /> <br />