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Environmc'4ta.1 ~[esl~h Sc%~;ices Di~ision <br />Varion fbur.ty D~ar~wcut of ~blic Health <br />Salem, (~'r,gon 97301 (588-5~6), ~ent for: <br />t)oDp_r~ue::t of Lk~viro~nt~ ~lity <br /> <br />To be &%lbmitted vrith application for <br />buitdinK pernZit or mobile he, ne place- <br />ment per~it. <br /> <br /> Application to the Dep~r~r~mt of Environmental Quality <br /> for a permit to Construct a New or .Repgi~- <br /> ~ Subsurface S~ewage Dis/$os~tul System <br />Permit Fees: New- ,{~oerf~ ($ ~)with ~ite evaluation) <br /> <br /> Re air Alteration - $13.00 <br /> <br />~ ~'~,I~CE INPOI~TION <br /> <br />City, State, ZiffC~e <br /> <br />S otion ,, <br /> <br />Tax Lot o~ AccOUnt # <br /> <br />B. CE52~/LL DF~CRTPTION <br /> <br />Nc~vConstruction <br /> <br />Installation will serve: <br /> <br />C~r~rcial Building <br /> <br />Nun~r of Living Units <br /> <br />Water Supply: Public <br /> <br />House <br /> <br />Installe~ ' s Name <br /> <br /> Repair <br /> <br />~.~bile Hcr~e /Mobile Home Park <br /> <br />Other (explain) <br /> <br /> N~m~e,r of Bedroca~ <br /> <br />Community <br /> <br />Pri%zte / GarbaEe Dispckgal.? ~ <br /> <br />C. ~!RED WgKHIBITS <br /> <br />1. Proposed Subsurface Sa~e Disloosal System Plot P!~n <br /> <br />2. Planning Evalustion -- Building Per, it <br /> <br />3. Building Plans <br /> <br />I hereby certify t~at the information contain¢~l in this application is true and correct <br /> <br />to the best o:f r~ knowl,ed~e and belief. <br /> <br /> No. <br /> <br />~II-57 7/74 <br /> <br />Date <br /> <br /> <br />