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Department of Environmental Quality <br />1234 s. w. Morrison <br />Portland, Oregon 97205 <br /> <br />Application to the Department of Environmental Quality <br /> <br /> for a Permit to Construct a <br /> <br /> New or Repair. a Subsurface Sewage <br /> <br /> Disposal SySt~ <br /> Permit Fees~ ~ .Re~air., Alteration $15.00 <br /> $50.00 ($25°00 ~ith site evaluation) <br /> <br />A. REFEP~ENCE iNFORMATION <br /> <br />L . Dwa'. .yne ~,. Lindley <br />N~me of Applicant <br /> <br /> 4928 - 13kb. v<:. NE <br />Addr e s s <br /> <br />City <br /> <br />B. GENERAL DESCRIPTION <br /> <br />Section 13 T 8 <br /> <br />Tax Lot or Account <br />Lo% size 22~ acrg.~ ....... <br />L~cation Rt. 2 Box 519 Aum~vi].ie <br /> <br />Installers Name <br /> <br />New Construction <br /> <br />Installation will serve: <br /> <br />Con~nercial Buildin~ <br /> <br />No. of Living Units <br /> <br />Water Supply: Public <br /> <br /> Re~air <br />House Mobile H~me <br /> <br /> Other (Explain) <br /> No. Bedrooms ,.3 <br /> COmmunity <br /> <br />Mobile Home Park <br /> <br />Private~Garbage Disposal? <br /> <br />c. REQUIRED EXHIBITS <br /> <br />Proposed Subsurface Sewage Disposal Syst~ <br /> <br />Plot plan <br /> <br />Planning Evaluation - Building Permit (Local Option) <br /> <br />Other (Local option) BuildinE ?!~ns <br /> <br />Permit No....~ ~ <br /> <br /> Da te <br />Interim Form ~1 <br /> <br />I hereby certify that the information contained ~a this application is true and <br />correct to the best of my knowledge and belief. <br /> <br /> /~Si~-nature (Owner/~ ~ta~l let) ~ <br /> <br /> <br />