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Environmental Health Services Division <br />M~r%on County Department of Public Realch <br />Salem, Oregon 97301 (588-5346), agent for: <br />Department of Environmental Quality <br /> <br />To be submitted with applieati~ for <br />building permit or mobile home place- <br />sent permafit. <br /> <br />Appltcetio~ to the Department of Environmental Quality <br />for a Per.it to Construct a New or R~,~iy <br />a Subsurface Sewage Disposal Bysgem <br /> <br />Permit Fees: New ~ $75.00 ($37.50 with site evaluation) <br /> <br />~epair~ Replace, Alteration - $25.00 <br /> <br />A, REFERENCE INFORMATION <br /> <br />Name of Applicant <br /> <br />9963 'iL1 L,['- :id. , u.n,v~. <br /> <br />Mailtng Address <br /> <br />City, State, Zip Code <br /> <br />Section .f'~/ <br /> <br />Twp Rge / ~ <br /> <br />Lot Size ] ,~cre <br /> <br />Property Address <br /> <br />Site Evaluation Serial Number <br /> <br />GENERAL DESCRIPTION <br /> <br />New Construction <br /> <br />Installation will serve: Hoese <br /> <br />installer' s Na~e <br /> <br /> check <br />Repair __ <br /> <br />Mobile Home x Mobile Home Psrk <br /> <br />Commercial Building____ <br />Number of Living Units <br />Water Snpply: Public __ <br />RE~R~E_~E]__D~_ !B ITS <br /> <br />I. <br /> <br />2. <br /> <br />3. <br /> <br />Other (explain) <br /> 1 <br /> <br />Con.unity__ <br /> <br /> Number of Bedrooms <br />Private x - Garbage Disposal? <br /> <br />Proposed Subsurface Sewage Disposal System Plot Plan <br /> <br />Planning Evaluation -~ Building Permit <br /> <br />Building Plans <br /> <br />I hereby certify that the information contained in this sp~lication is true and correct <br />to the best of my knowledge and belief. ~O~) ~7 ~ [] / <br /> <br />Permit No. ~ <br /> <br /> _ ....... <br /> Date <br />~{-57 few 12/76 <br /> <br /> <br />