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Environmental Health Services Division <br />5ig.rion County Depar~t of Public Health <br />8'alam, Oregon 97301 (588-5~46), a~ent for: <br />Department of Envirom~ntal Quality <br /> <br />To be s~bmitted with application for <br />building permit or mobile h~me place- <br />ment pe~it. <br /> <br />Application to the ~partr~nt of Environmental Quality <br />for a Perm/t to Construct a N~v or R~pair <br />a Subsurface S~e Disposal Syst~ <br /> <br />PeaTait Fees: <br /> <br />New - $50.00 ($25.00 with site evaluation) <br /> <br />Repai~ Alteration - $15.0o <br /> <br />Pacific N. W. Development 90~p. _ <br />~ of Applicant <br /> <br />Section ll T 4 S R 1 W W.M. <br /> <br />919 Wisteria Br,, Rt. 2 <br />~i%iliSg Addres~ <br /> <br /> Aurora, OR. 97002 <br />Ciiy, ~tate, ZiP~de <br /> <br />Tax Lot or Acoou~t # <br /> <br />Lot Size lO.000 em ft. <br /> Lot 4, Blk 12 <br /> 495 Wip~eria Dry, Et, ~ .... <br />P~oper~y Address <br /> <br /> John Waite <br />'~nstall.~'s N~e <br /> <br />New Construc2ion X <br /> <br />Repair <br /> <br />Installation will serve: tMuse Hobile Hc~ne ...X <br /> <br />Mebile Hf~e Park <br /> <br />Cc~reial Building_, Other <br /> <br />Number of Living Units <br /> <br />Water Supply: Public ... Cc~amunity x Private <br /> <br />N~m~ber of BedL~cms } ..... <br /> <br />Garbage Disposal? x <br /> <br />C, ~.~. 3!RED EXHIBITS <br /> <br />1. Proposed Subsurface Sewage Disposal System Plot Plan <br /> <br />2. Planning ~u~i~ m-- Building Permit <br /> <br />3. Building Pl~us <br /> <br />I hereby certify that the inforr~xtion contained in this application is true ~d correct <br /> <br />to the best of my lmowl.edge and belief. <br />Pen~,t NO. ~ ~q .... <br /> <br />Isc. ed .% <br /> <br />7/74 <br /> <br /> <br />