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Environmental Health Services Division <br />'M~fion County Department of Public Health. * To be submitted with application for <br /> Salem, Oregon 9%301 (588-5346), agent for: building permit or mobile home place- <br /> Department of Enviroronental Quality ment pe~nni~. <br /> <br />Applica~ion to the Dspartment of Environmental Qualtey <br />for a Permit to'Cons~r~st a New sr ~.r <br />a Subsurface Sewage Disposal System <br /> <br />Rcl~.~ir~ 'Replace~ 'A!te~atio_~n - <br /> <br />R~,~ BRLNCE %NI?ORMATION <br /> <br />Ma~ ling Address <br /> <br />City, State, Zip Code <br /> <br />Sits Evaluation Serial Numbmr <br /> <br />GENERAL DESCRIPTION <br /> <br />New ~onsgructisn <br /> <br />Inst~llation will serve: <br /> <br />Com~srcial Building__ <br /> <br />Mt~%~er of Living Units <br /> <br />Installer's Nsme <br /> <br /> O~her (explain) <br /> <br />~ater Supply: PCbl±e ~¢ommun±¢y ....... <br /> <br />REQUIRED E~tIBITS <br /> <br />1. Proposed Subsurface Sewage Disposal System Plot <br /> <br />2. Planning Evaluation -- Building Permit <br /> <br />3. Building Plans <br /> <br /> Repair,,,,,,,,,~' <br />.... Mobils ~,ome ~ Mobile Hems Park., <br /> <br /> Mu~er of Bedrooms .... <br /> <br />Private Garbage D~sposai? <br /> <br />I hereby certify that the information contaipe~n this application isq~/and core, et <br />to t~,~ b~s~ of ~,y ~.o~le~e end ~li~. / / ~ ,,,,,(///~ I/ -' <br /> <br /> /s~g~U'~ ~: , ' ...... <br /> <br /> ~a¢~ ................... <br />B~-57 rev. 12176 <br /> <br /> <br />