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Environmental tIealth Services Division <br />Marion County Departm~mt of Public Health <br />Salem, Oregon 97301 (558-5~46), agent for: <br />Department of Enviro~nental ~m,lity <br /> <br />To be submitted with application for <br />building permit or mobile home place- <br />~nt pei~*uzt. <br /> <br />Applicatic~ to the Pep~rt~nt of Enviromuental .Quality <br />for a Permit to Construct a Now or P~pair <br />,..% Sub--face S~r~age Disposal System <br /> <br />Permit Fe~s: New ~ $50.00 ($25.00 vrith site evaiuation) <br /> <br />R~ioair~ Alteration - $15.00 <br /> <br />A. ~"~.'ER~3~CE IIQTORNATION <br /> <br /> Charles Chappelle <br />~ of Applicant <br /> <br /> ~ 3375 48th Ave NE <br />~ailing Address <br /> <br /> Salem <br />City, State, Zip Code <br /> <br />Sect ion 1 l <br /> <br />Tax Lot or Account # <br />Lot Size 1 acre <br /> <br />T 8 R 2w <br /> <br /> 8376 Kedwood Dr, SE~ Aumsvllle <br />Property Address <br /> <br />Ins~alter~s Name <br /> <br /> 5~obile }Ic~e P~k <br /> <br />B. GFi~3~L ~IPTiON <br /> <br />New Cx)nstruction <br />Installation will seZ~ze: <br />Commercial Building <br />Nut,ocr of Living Units <br />r;~ater ~lpply: Public <br /> <br />x Repair <br />House x ~obile Heine <br />Other (explain) <br /> <br />Coam~mity <br /> <br />N~nber of I~droom$ 3 <br /> <br /> Private ~urbe~ge D~sposal.. <br /> <br />no <br /> <br />C. .PtI73IRk~HIBI~ <br /> <br />1. Proposed Subsurface Sewage Dis~)sal System Pier P!~.un <br /> <br />2. Planning Evaluation -- B~ildingPer~it <br /> <br />3. ~ailding Plans <br /> <br />I h¢:.reby certify t.'_~t the information e~ntained in this application is true amd correw~t <br />to the best of ~ l~owl~e m~d belief. <br /> <br />Isled ~ <br /> <br />7/74 Ds~te <br /> <br /> <br />