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Department of Environmental Quality <br />1234 s. w. Morrison <br />Portland, Oregon 97205 <br /> <br /> Application to the Department of H~vironmental Q~ality <br /> <br /> for a Permit to Construct a <br /> <br /> New or Repai~ a Subsurface Sewage <br /> <br /> Disposal System <br /> <br /> Permit Foes: New ~ Repair, Alteration $15.00 <br /> $~0.00 ($2~.00 with si%e eYalua%ion) <br /> <br />REFERENCE INFORMATION <br /> <br />,N~uae of Applicant <br /> <br />Address <br /> <br />City <br /> <br />B. GENERAL DESCRIPTION <br /> <br />Tax Lot or Account <br /> Lot s~ze /~ ~ <br /> <br /> ~,n~ ~)1~,1~ ~ -5~,,~, ~ <br /> <br />New Construction ~ <br /> <br />Installation will serve: <br /> <br />Commercial Building <br /> <br />NO. of Living Unite ---1__ <br /> <br />Water Supply: Public ~__ <br /> <br />~epair <br /> <br /> Mobile Home <br /> <br />Other (E~plain) <br /> <br />No. Becl~ooms <br /> <br /> Community <br /> <br />Mobile HC~ae Park <br /> <br />Private <br /> <br />Garbage Disposal? <br /> <br />REQUIRED EXHIBITS <br /> <br />1. Proposed Subsurface Sewage Disposal Syst~'~ <br /> Planning EValuation - Building Permit .(Local O~tion) <br /> <br />3. Other (Local Option) B%~ildin~ Plans <br /> <br />I hereby certify that the information contained in this application is true <br />correct to the best of my knowledge and belief. <br /> <br /> Signature (Owner/Installer) ( <br /> <br /> ~a te <br /> <br />Interim Form #1 <br /> <br /> <br />