Laserfiche WebLink
Environmental HealZh Services Division <br />~arion County Department of Public Health <br />Salem, Oregon 97301 (5SS~534~3), agent for: <br />Department of Env~,~nta]_ Quality <br /> <br />To be submitted with application for <br />building, permit or r~obile hc~e place- <br />ment <br /> <br />Application to the Department of Environmental Quality <br />for a permit to Construct a N~¥ or R,~,pair <br />a Subsurface Sewage Disposal System <br /> <br />Permit Fees: <br /> <br />New - $50.00 ($25.00 with site evaluatiou) <br /> <br />Repair, Alteration - $15.00 <br /> <br />A. ~"~I~CE INFORMATION <br /> <br /> '~alter E. BlOck <br />Name of Appiica~t <br /> <br /> Rt. 3, Box 33 <br /> <br />Sherwood~ CR 97140 <br />'C'i'ty, State, zip Code' <br /> <br />Section 13 T 4 R 2w <br /> <br />Tax Lot or Account # <br />Lot Size. 15 acres <br /> <br /> Rt. 1~ Box 126B, ~urora <br />Property Address <br /> <br />Installer" s N~me <br /> <br />New Construction <br /> <br />Installation will serve', <br /> <br />Repair <br /> <br />House x Mobile Home <br /> <br />~cbile Home Park <br /> <br />Cz3~nercial Building . <br /> <br />Number of Living Units <br /> <br />Other (explain) <br /> <br /> Number of Bedrocks <br /> <br />Wa~er Supply: Public Cc~T~nity Private x Garbage Disposal? no <br /> <br />c. rc rmD Z!.Z,SZTS <br /> <br />1. Proposed Subsurface Sewage Disposal System Plot Plan <br /> <br />2. Planning Evaluation -- Building Pe~nit <br /> <br />3. Building Plans <br /> <br />Permit No.., U3.~ ~ <br /> <br />I hereby certify that the information contained in this application is true and correct <br />to the best of my knowledge and belief. <br /> <br /> Signature (owner/installer) <br /> <br />EH-57 7/74 <br /> <br /> <br />