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Environmental Health Services Division <br />Marion County Department of P~lic Health <br />Salem~ Oregon 97301 (588-5346), agent for: <br />Department of Enviror~ntal Quality <br /> <br />To be submitted with application for <br />building permit or mobile home place- <br />ment permit. <br /> <br />Application to the Department of Environmental Quality <br /> for a Permit to Construct a New or <br /> a Subsurface Sewage Disposal System <br /> <br />Permit Fees: ~e~w - $75.00 ($37.50 with site evaluation) <br /> <br />Replace, Alteration - $25.00 <br /> <br />A~ R£FERENCE iNFORMATION <br /> <br /> Joyce Niwkirk <br />Name of Applicant <br /> <br /> 174q5 Brown Rd. <br />Maili~g Address <br /> <br /> Dal las 9733~ <br />City, State, Zip COde <br /> <br />Site Evaluation Serial Number <br /> <br />Section 13 Tw-p 9s Rge 2w <br /> <br />Tax Lot or Account # <br /> <br /> 1~76 Maple St. ~umsville <br />P~operty Address <br /> <br />Mel Saw%er <br /> <br />Installer's Name <br /> <br />GENERAL DESCRIPTION <br /> <br />New Construction <br /> <br />Inatallation will serve: <br /> <br />Repair check <br /> <br />Mobile Home x Mobile Home Park <br /> <br />Commercial Building <br /> <br />__ Other (e~plain) <br /> <br />Number of Living Units <br /> <br />1 <br /> <br />Number of Bedrooms 2 <br /> <br /> Water Supply: Public x Corm~unity <br />C. ,REQUIRED E~I'IBITS <br /> <br />__Private__Garbage Disposal? <br /> <br />1. Proposed Subsurface Sewage Disposal System Plot Plan <br /> <br />Planning Evaluation -- Building Permit <br /> <br />3. Building Plans <br /> <br />to the best of my knowledge and belief. <br />Permit No. <br /> <br />I hereby certify that the information contained in this application is true and correct <br /> Date <br /> <br />EH-57 rev. 12/76 <br /> <br /> <br />