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Environmental Health Services Division <br />Marion County Department of Public Health <br />Salem, Oregon 97301 (588-5346), agent for: <br />Department of Environmental Quali~y <br /> <br />To be submitted with application for <br />building permit or mobile home place- <br />ment permit. <br /> <br />Application to the Department of Environmental Quality <br /> for a Permit to Construct a New or <br /> a Subsurface Sewage Disposal System <br /> <br />Peri, it Fees: New - $75.00 ($37.50 with site evaluation) <br /> <br />R~air~Replace~ 'Alteration - $25.00 <br /> <br />A. REFERENCE INFORMAT~.ON <br /> <br /> WJ.].~::is Martilla <br />Name of Applicant <br /> <br />Route 1 Box Jl <br />Mailing Address <br /> <br />City, State, Zip Code <br /> <br />Section 16 Twp 48 Rge 1W <br /> <br />Tax Lot or Account <br /> <br />Lot Size <br /> <br />P~operty Addres~ <br /> <br />Site Evaluation Ser~ai Number <br />GENERAL DESCRIPTION <br /> <br />New Construction x <br /> <br />Installation will serve: House <br /> <br />Instelter's Name <br /> <br /> Repair <br /> <br />Mobile Home <br /> <br />x Mobile Home Park <br /> <br />Commercial Building <br />Number of Living Units <br />Water Supply: Public <br />REQUIRED EXHIBITS <br /> <br />1. <br /> <br />2. <br /> <br />3. <br /> <br />,,__Other (explain) <br /> <br /> 1 <br /> <br />__ Community <br /> <br /> Number of Bedrooms ~ <br />__Private ~ Garbage Disposal? <br /> <br />Proposed Subsurface Sewage Disposal System Plot P%an <br /> <br />Planning Evaluation -- Building Permit <br /> <br />Building Plans <br /> <br />no <br /> <br />hereby certify that the information contained in this application i~ true and correct <br /> <br />to the best of my knowledge and belief, <br />Permit No, _,,,,,~/, <br /> <br /> ssued ?fl _ <br /> <br />EH.-57 rev, 1.2/76 <br /> <br /> <br />