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Envi~omucutal Health Services D~¥~sioq" <br /> County Departme~lt of Public; {ealth <br /> Oregon 97~)1, (588-5346)~ ~lgc~lt t,o~.: <br />D~gartment ~ Enviroume,~al Quality <br /> <br />To bc ~ttblnitted with applica~lom for ' ' <br />lm:i.ld:h~g permit or mobile home place- <br />merit porml~. <br /> <br />Appticatiml to l'b(% l)epartmmlt of Enviroamelltal' <br /> for a Permit to Consttu_%'_t.'. a New or <br /> a Subsurface Sewage Disposal System <br /> <br />Permit Fees: New -.~J~'~ ~i~-wltb si~e evaluation) <br /> <br />A~ RI:FERENC;" iN iq)R}tA'r I ON ~ <br /> '~l~e of Applicant <br /> <br /> Proper ty Add~ess <br /> <br />· N~W (,opstructl. on ,~x,~..~ ~ _, Repair . __ · · . <br /> installation will l~crv~: }toose'.~_._ Mobile Home ...~_ Mobile Home Park <br /> Commercial Bui.ldin~ _____ Other (axp.lafn) <br /> <br /> Number of Liv~ng Units / Number of Bedrooms <br /> <br /> Water Supply: Public ...... Co~2nunity .~ Private Garbage Disposal? <br /> <br /> 1. Proposed Subsarfacc Sewage Dispooal Sysgkn Plot Plan <br /> <br />2. PI. stating Evtliualtlotl' ~- Bufiding Permi2 <br /> <br />3. Bk~t I<ling P,kanu <br /> <br /> hereby ccrtl, i~y that thc ,i. nietmat,.ton cm~tained.jj% this ~pplica~ioll~ue end <br />tile best of my know.ledgl, and b~il.ci. //) ..... ~,' . // ~ <br />I'~mlt No. ~ / _. ~.~ . <br /> Sign ute <br />Io~ued <br /> <br /> ,,. ..... <br />Ei1-l~l rev, 12/76 <br /> <br /> <br />