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Environmental Health Services Division. <br />~,~rion County Department of Public Health <br />Salem, Oregon 97301 (588-5346), age. Dt f6r: <br />Depa~ h~ent of Environmental Quality <br /> <br />To be submitted with application for <br />building permit or mobile home place- <br />merit permit. <br /> <br />Application to the DepP~rtment of Enviromnental Quality <br />for a Permit to Construct a New or Repair <br />a 5~bsurf~ce Sewage Disposal System <br /> <br />Permit F£es: Nc~v- $50.00 ($25.00with site evaluation) <br /> <br />Repair, Alteration - $15.00 <br /> <br />P~i,'i~JiiENCE INFOB~gATION <br /> <br />Mailing Addreos~ <br /> <br />City, State, Zip <br /> <br />Section ~. <br /> <br />Tax Lot or Account # <br /> <br />Lot Size <br /> <br />~roperty ' Addres~ <br /> <br />Installer ' s Name <br /> <br />B. GE~E~ DESCRIPTION <br /> <br />Nc~v Construction <br /> <br />Installation will serve: <br /> <br />House <br /> <br /> Repair <br />/'~obileHome <br /> <br />Mcbile Home Park <br /> <br />Commercial Building <br /> <br />Number of Living Units <br /> <br />Water Supply: Public <br /> <br />Other (explain) <br /> <br /> / Number Of Bedromrs ~7~ <br /> Osramunity /PriVate __ GarbaEe Disposal? <br /> <br />REQUIRED E~IIBITS <br /> <br />1. Proposed Subsurface S~e Disposal Systa~u Plot Plan <br />2. plannir~ Evaltu%tion -- Building Pexlnit <br /> <br /> Building Plans <br /> <br />I hereby certify that the information contained in this application is true and correct <br /> <br />to the best of my knowledge and belief. <br /> <br /> No. <br /> <br />~-I-57 7/74 <br /> <br />Date <br /> <br /> <br />