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Envirommental Health Services Division <br />Marion CountM Dep~%rtment of Public 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 />meat permit. <br /> <br />Application to the Department of Environmental Qumli~y <br />for a Permit to Construct a New or'Repair <br />a Subsurface Sewage Disposal System <br /> <br />Permit Fees: ~.ew - $75.00 ($37.50 with site evaluation) <br /> <br />Repair, Replace, Alteration - $25.00 <br /> <br />REFERENCE INFOR~T%ON <br /> Eugene Kelly <br /> <br />Name of Applicant <br /> <br /> 5?75 Shew Hwy. Sm <br /> <br />Mailing Address <br /> <br /> ~ Aumsville 97825 <br /> <br />City, State, Zip Code <br /> <br /> ..... '' , i!~ <br />Section _ Twp ~, ,~2, Rge i. <br /> <br />Ta~ Lot or Account # <br /> <br />Lot Size 5 acres~ <br /> <br />S 775 Shaw Hwy. <br />Property Address <br /> <br />Site Evaluation Serial Number <br />~EN.ERAL~D_~E~RIPTION <br /> <br />New Construction x <br /> <br />Insta].lat~on will serve: House <br /> <br />Installer's Name <br /> <br />Commercial Building __.--- <br /> <br />Number of Living Units <br /> <br />Water Supply: Public <br /> <br />~EQUIRED EXHIBITS <br /> <br />2. <br /> <br />3. <br /> <br /> Repair <br /> <br />Mobile Home <br /> <br />Other (explain) <br /> <br />X <br /> Mobile Mome Park <br /> <br />3 <br /> <br />1 <br /> <br />Number of Bedrooms <br /> <br />Community __ <br /> <br />Private x Garbage Disposal? <br /> <br />Proposed Subeurface Sewage Disposal SysCem Plot P%an <br />Planning Evaluation -- Building Fermit <br /> <br />Building Plans '' <br /> <br />I hereby certify that the information contained in this application'is true and correct <br />t° the best °f mY kn°wledge and belief' ~ ~ //~ <br />Permit ~o. ,,'~-CT ~5 ~ ' <br /> ~ / Signat~r~ ] / ~ /~ ...... <br /> <br /> <br />