Laserfiche WebLink
Enviroamental Health Services Division <br />Marion Cx~unty D~partment of Public Health <br />Salam, Oregon 97301 (588-5346), agent for: <br />DepD~t~mt of Environmental Quality <br /> <br />To be submitted with application for <br />building permit or mobile home place- <br />me,ut perrMt. <br /> <br />Application to the Department of Environmental Quality <br />for a Permit to Construct a New or P~pair <br />a ~ubsurfaee Sewage ~sposal Systam <br /> <br />Permit Fces: <br /> <br />Nc~v- $50.00 ($25.00 with sits evaluation) <br /> <br />.R. epair, Alteration - $15.00 <br /> <br />Tax Lot or Account # <br />Lot Size ~ ? C3 >d ,,,./-~- d3 .-' . ~)7/, <br /> V <br /> ...... <br />ProperW ~ddress ' <br /> <br />New Construction t/~ 5 - <br /> <br />Installation will s~rve: House <br /> <br />Commercial Building_ <br /> <br />Number of Living Units <br /> <br />Water Supply: Public__ <br /> <br />Installer ' s Name <br /> <br /> Repair <br /> <br /> Mobile Hcme <br /> Other (explain) <br /> <br />__ / <br /> <br /> Cca~unity <br /> <br />~bile Hc~e Park <br /> <br />Number of Bedrocrns ~ <br /> <br /> Private ~f Garbage Disposal? <br /> <br />C. REQUIRED EXItIBITS <br /> <br />1. Proposed Subsurface Sewage Dis!oosal System Plot Plmu <br /> <br />2, Planning Evaluation -- Building Permit <br /> Building Plans <br /> <br />I hereby certify that the information contained in this application is true and correct <br />to the best of r~y knowledge and belief. <br /> <br /> Signature (owner/installer) <br /> <br />76 <br /> <br />EH-S7 7174 Date' <br /> <br /> <br />