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Envirozunental Health Services Division <br />Marion County Department of Public Health <br />Salem, Oregon 97301 (588-5346), agent for; <br />Departmemt 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 Construct a New or'Repair <br />a Subsurface Sewage Disposal System <br /> <br />Permit Fees: N~_~ - $75.00 ($37.50 with site evaluation) <br /> <br />Repair~'%eP!ace, Alteration - $25.00 <br /> <br />REFERENCE INFORMATION <br /> <br />Name Of APpli~'a~ <br /> <br />Mailing Address <br /> <br />tity, ls~a~8, Zip Code <br /> <br />Section <br /> <br />Tax Lot or Account <br />Lot Size <br /> <br />Property Address <br /> <br />Rge <br /> <br />Site Evaluat'ion Serial Number <br /> <br />B. GENERAL DESCRIPTION <br /> <br />Instaiier's Name <br /> <br />New Construction <br />Installation will serve: <br />Commercial Building <br />Number of Living Units <br />Water Supply: Public <br />REQUIRED EXHIBITS <br /> <br />1. <br /> <br />2. <br /> <br />Repair <br /> <br />House ~ Mobile Home Mobile Home Park <br /> <br />__Other (explain) <br /> Community, <br /> <br /> Number of Bedrooms ~ <br /> <br />Private __ Garbage Disposal? <br /> <br />Propomed Subsurface Sewage Disposal System Plot P%an <br /> <br />Planning Evaluation l-- Building Permit <br /> <br />3. Building Plans <br /> <br />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. ~.~ ll <br /> <br />m~157 rev. 12/76 <br /> <br /> <br />