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To, ENVIRO~$~NTAL HEALTH ~E~-I6~ DIVISION, ~on Co. Me~%h Dept., S~em, OR 97301 <br /> <br /> (n~e ~ ~ress o~le~g ~e~ or bthers r~u~t~g <br /> SubJ~t: ~e~ f~ ~e~igati~ ~ ~ation ~ on water <br /> dwelling or other ~t=es l~.t~ at~Y{~.~.~ <br /> ....... <br />~25.~ fee enclosed. <br /> <br /> (Date) ~(Si~at~e) <br /> <br /> (for He~th Dep~nt use o~) <br />To: L~ndmng age~y or other as ~ted ~e. <br />Water S~: Accept$1e ~; Not acceptable ; (Laborato~ re~ ~ ~7-~.~h$~ <br />(1) Well pro~r~ se~ed ~ ~gtected ~ s~f~e cont~nation: Yes ~ No <br />(2) ~oper ~pply ~otectton is essenti~. ~e follo~ng defects (if ~) ne~ to be <br /> co~ected before a me~n~ s~le c~ be co~ect~ for <br /> <br />(3) Location of well: <br /> <br />COMMEN'~: <br /> <br />Sewage Di.'~osal System: Acceptable acceptable , <br />(1) Record of ezimbing ~ystem? <br /> <br /> Yea No <br />(2) Evidence of malfunction? <br /> Yes No <br />(3) Soils generally acceptable for septic system? <br /> <br />(A) Room for system expansion? <br /> <br />¥e--7 ~o <br /> <br />Yea N--g- <br /> <br />(5) Required distance from well? <br /> <br />From stream? (if an~) <br /> Ye s No <br /> <br /> P~ ,;~c He~al~W S~f~ar~an <br /> ~sI~ect~r 0r <br /> <br /> <br />