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Environmental Health Services Division <br />Marion County Department of Public Health <br />Salem, Oregon 97301 (588-5346), agent for: <br />Department of Environmental 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'Constract a New or'Repa~F' <br /> a Subsurface Sewage Disposal System <br /> <br />R_~3~air,'Replace,'Alteration - <br /> <br />A.' REFERENCE INFORMATION <br /> <br />£: z. A ~z a .4, F5 i-c.~-t <br /> <br />Name of Applicant <br /> <br />H?,O, ~Jo~ Sc.,-/ <br /> <br />Mailing Address <br /> <br />0~.. -~TtOF;-~ of L. c:/'7 '.J 4' Z._ <br /> <br />City, State, Zip Code <br /> <br />section____/__ lO _,,,.%,"/ <br /> <br />· Lot or Account <br /> <br />Lot Size <br /> <br />Property Address <br /> <br /> Site Evaluation Serial Number <br /> <br />B. GENERAL DESCRIPTIO~ <br /> New Construction <br /> Installation will serve: <br /> Commercial Building <br /> Nt~ber of Living Units <br /> Water Supply: Public <br /> <br />C. REQUIRL~D EXMIBITS <br /> 1. <br /> 2. <br /> 3. <br /> <br />Installer~s Name <br /> <br />House u/ Mobile Home Mobile Home Park <br /> <br />__Other (explain) <br /> <br /> Number of Bedrooms 0.~ <br />__ Community ~/ Private__ 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 application is trne and correct <br />to the beat of my knowledge and belief. <br /> <br />Permit No. <br />Issued <br /> <br />Signature <br /> <br /> Date <br />rev. 12/76 <br /> <br /> <br />