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Envirommental Health Services Division <br />Marion County Department of Pnblic 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 Quality <br /> for a Permit to C0nstruct a New or ~f_r <br /> a Subsurface Sewage Disposal System <br /> <br />Permit Fees: New ~ $75.00 ($37.50 with site evaluation) <br /> <br />R~pair, Replace, Alteration ~ $25.00 <br /> <br />REFERENCE INFORMATION <br /> <br /> Pstri?k ~{- NcGarvey <br /> <br />Name of Applicant <br /> <br />Section <br /> <br />Rt. 2 l$ox 196 <br /> <br />Mailing Address <br /> Aurora, Or. 97002 <br /> <br />~ity, St~-~e' zip Coda <br /> <br />Tax Lot or Account # <br /> <br />Lot Size <br /> <br />acres <br /> <br />Property Address <br /> <br /> Site Evaluation Serial Number <br /> <br />B. GENERAL DESCRIPTION <br /> New Constructios , <br /> Installation will serve: <br /> Commercial Building <br /> Number of Living Units <br /> Water Supply: Public__ <br /> <br />C. REQUIRED EXHIBITS <br /> 1. <br /> 2. <br /> <br />Installer's Name <br /> <br /> Repair check <br /> <br />House Mobile Home x <br /> <br />Other (explain) <br /> <br />Community <br /> <br />Mobile Home Psrk <br /> <br />1 Number of Bedrooms 2 <br />__Private__ Garbage Disposal? no <br /> <br />Proposed Subsurface Sewage Disposal System Plot Plan <br /> <br />Planning Evaluation -- Building Permit <br /> <br />Building Plans <br /> <br />I hereby certify tha~ the information contained in this application is true and correct <br /> <br />to the best of my knowledge and belief. <br />Permit No. 'Y/f~ <br /> <br />EH-57 rev. 12/76 <br /> <br />Date <br /> <br /> <br />