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Enviroo~ental Health Services Division <br />~larion County Depar~nt of Public Health <br />Sa/am, eregon 97301 (555-5~!~), agent for: <br />Department of Enviromneatal Quality <br /> <br />TO be m~hnitted with application for <br />buildL~g permit or mobile l~onoe place- <br />rnent pc-r~it. <br /> <br />Application] to the r~artment of EnviroDmental .quality <br /> for a Per.it 'to Construct a New or <br /> a Subsurface Sewage Disposal <br /> <br />Permit Fees: New $50.00 ($~o. OOwith site evaluation) <br /> <br />R%oair~ Alteration ~ $15.00 <br /> <br />R'~'E[~qCE INFOENATION <br /> <br />~,~ilin~ A~sS ~ ' <br /> <br />City, State, Zip ~o <br /> <br />Sect ion T R <br /> <br />Tax Lot or Account # <br />Lot Size - <br /> <br />Propert.v ~d~SS <br /> <br />B. G~m59f~L DES~,It~rioN <br /> <br />N~v Construction <br /> <br />Installation will se!we: <br /> <br />Commercial Building <br /> <br />Number of Living Units <br /> <br />Water Supply: Public__ <br /> <br />Install¢~ ' s Name <br /> <br /> Repair <br /> <br /> Ho~se / ~.~bbile Hc~e <br />Other (explain) <br /> <br /> / <br /> Co~wmmity <br /> <br />Mcbile }~m~e P~rk <br /> <br />Ak~r of Bc~ocms _~ <br /> Private /' Garbage Disposal? <br /> <br />C. RAT~U!PIlD I~IIBITS <br /> <br />1. Proposed Subsurface S~vage Disposal Syst~nPlot Plan <br /> <br />2. Planning Evaluation -- Building Permit <br /> <br />3. ~ailding Plums <br /> <br /> 1~ true and correct <br />I lwireby certify th~at the information contained in this application <br /> <br />Signature [owner/installez~ ~ % <br />Date <br /> <br /> <br />