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Environmental Health Services Division <br />~arion County Department o£ Public Health <br />Salam, Oregon 97301 (588-534_6), agent for; <br />Department of Envirop/nentsf[ Qk~.lity <br /> <br />To be submitted with application for <br />buildiDg permit or mobile hc~e place- <br />m~t permit. <br /> <br />Application to the D~p~gmtm'eut of Envircr~nental Quality <br />for a persHt to Construct a New or ~ <br />a Sub~rf~e Sewage Disposal System <br /> <br />Per.it Fees: New - $50.00 ($25.00 with site evaluation) <br /> <br />Repair, Alteration - $15.00 <br /> <br />A. P~FERti~ INFOm~TION <br /> <br /> k Ra~ Foster <br />Name of Applicant <br /> <br /> 47]0 T~h~r~v <br />~&ailing Address <br /> <br />City, State, Zip Code <br /> <br />Secti°n~2 ~ !3 <br /> <br />T ~ ..... R 2w <br /> <br />T~x Lot or Account # <br /> <br />Lot Size 4.35 acres <br /> <br /> 4768 Dumore Drive <br />Property Address <br /> <br />Installer's Name <br /> <br /> ~bile }IomeP~k <br /> <br />B. GE~EP~ D~IFrION <br /> <br />New C~anstruction <br /> <br />Installation will serve: <br /> <br />Co~uercial Building <br /> <br />Number of Living Units <br /> <br />Water Supply: Public__ <br /> <br /> x Repair <br /> <br /> House x ~obile Home <br />__ Other (explain) <br /> <br />Conrmmity <br /> <br />Number of Bedrooms 3 <br /> <br /> Private Garbage DisR0osal? Yes <br /> <br />C. RII~IREDE~{IBITS <br /> <br />1. Proposed Subs%trface Sewage Disposal SygtemPlot Plan <br /> <br />2. Planning Ev~luation -- Building Permit <br /> <br />3. Building Plains <br /> <br />I hereby certify that the irLformation contained in this application is true and correct <br />to the best of my knowl~tge and belief. <br /> <br />Pemit ? , <br /> Sigrf~tur s (owner/installer) <br /> <br />EH-57 7/74 Date <br /> <br /> <br />