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Environmental Health Services Division <br />~arion County DepartEent o£ Public Health <br />Salem, Oregon 97301 (581~-53_~), a~mt for: <br />Dep.artment of ~nvirom~nZml Q~zlity <br /> <br />To be submitted with a~lication for <br />building permit or raobile ho~e place- <br />memt permit. <br /> <br />Application to the Dep~ln~nt of Environmental Quality <br />for a Permit to Construct a New or ~ <br />.% Subsurface Sewage Di~0os~l Syst~n <br /> <br />Permit Fees: New - $50.00 ($25,00 with site evaluation) <br /> <br />Re. ir Alteration - $15.00 <br /> <br />Section ,/3 <br /> <br />Tax Lot or Account # <br /> <br />Property Address <br /> <br />B. Gm~EP~L DESCRIPTION <br /> <br />New Constr~ction <br /> <br />Installation will serve: <br /> <br />Co~rcial Building <br /> <br />Nttmber of Living Units <br /> <br />~kater Supply: I~blic <br /> <br />Installer's Name <br /> <br /> Repair <br /> <br /> House /~,fobile Home <br />Other (explain) <br /> <br /> Cc~a~unity <br /> <br />Mebile ~k~me Park <br /> <br />C. ~J!RED E~dqIBITS <br /> <br />1. Proposed Subsurface Sewage Disposal System Plot Plan <br /> <br />2. Planning Eval.uation -- Building Permit <br /> <br />3. Build~lgPl~us <br /> <br />I hereby certify that the information contaiued in this~application is true ~ud correct <br />to the best of my knowledge and belief. ~ <br /> Signatt6re (owner/installer) <br />Issued <br /> <br />EH-57 7/74 Date <br /> <br /> <br />