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Environmental Health Services Division <br />Marion County Department of Public Health <br />Salem, Oregon 97301 (588-5346), agent for: <br />Depart~e~t 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 Environmeatal Quality <br />for a Permit toC0n$~uct a New or'Repair <br />a Subsurfa(!e Sewage Disposal System <br /> <br />Permit Fees: Ne~W- $75.00 ($37,50 with site evaluation) <br /> <br />Repair, Replace~ Alteration - $25.00 <br /> <br />A. REFERENCE INFORMATION <br /> <br />Name of Applicant <br /> <br /> 12218 H~:~tch L=lne <br /> <br />Mailing Address <br /> <br /> ,,.umsvil/a, Oregon <br />City, State, Zip' ~ode"' <br /> <br />97325 <br /> <br />Section Twp .... Rge <br /> <br />Tax Lot or Account # ...... <br /> <br />Lot Size 4,~/2 acres <br /> <br />Site Evaluation Serial Number <br /> <br />B. GENERAL DESCRIPTION <br /> <br />ins~aii~r'a Name <br /> <br />New Construction ~d ~tion <br /> Repair <br /> <br />Installation will serve: Housexx Mobile Home <br />Commercial Building ,__Other (explain) <br /> <br />Number of Living Units 1 <br /> <br />Water Supply: Public~Co~unity .... <br /> <br />REqUiRED EXHIBITS <br /> <br />Mobile Home Park <br /> <br /> 3 <br />Number of Bedrooms ....... <br /> <br />. Private .~,, Garbage Disposal? <br /> <br />I. Proposed Subsuriace Sewage Disposal System Plat Plan <br /> <br />2. Planning Evaluation -.- Building Permit <br /> <br />3. Building Plans <br /> <br />I hereby certify that the information contained in this application is J~rue and correct <br />to the best of my knowledge and belief. ......~ / ~ <br /> <br /> Date <br />EM-57 rev. 12/76 <br /> <br /> <br />