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Department of Environmental _Quality <br />1234 $. w. Morrison <br />Portland, Oregon 97205 <br /> <br />Application to the Department of Environmental Quality <br /> <br /> for a Permit to ~Rnstruc~ a <br /> <br /> New or ~paira Subsurface Sewage <br /> <br /> Disposal Syst~ <br /> <br /> Permit Fees: New $30.00 Rel~air, Alteration $15.00 <br /> <br />A. REFERENCE INFORMATION <br /> <br />City <br /> <br />B. GENERAL DESCRIPTION <br /> <br />Tax Lot or Account <br /> <br />Installers Name <br /> <br />New Construction <br /> <br />Installation will serve: <br /> <br />Commercial Buildin~ <br /> <br />NO. of Living Unite <br /> <br />Water Supply: Public <br /> <br />~ther (Explain) <br />NO. Bedrooms ~ <br />Co~nunity_ <br /> <br />Repair <br /> <br /> Mobile Home <br /> <br />Private <br /> <br />Mobile Home Park <br /> <br />arbage Disposal? <br /> <br />C.~' .REQuIP~ED EXHIBITS <br /> <br />Proposed Subsurface Sewage Disposal Syst~ <br /> <br />P10% Plan) <br /> <br />Planning Evaluation - Building Permit .(Local 09ti0n) ........ <br />Other (Local Option)~?lans <br /> <br />I hereby certify that the information contained in this application is true and <br />correct to the best of my knowledge and belief. <br /> <br />Permit No. <br /> <br />Issued <br /> ~te <br />Interim Form <br /> <br />Signature (Owner/Installer) <br /> <br />Bate /92 <br /> <br /> <br />