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~ fOR~ ' set. no. 4-77-1 rec. #5023 <br />STATEMENT OF FEASIBILITY FOR PROPOSED SUES~RFACE SEWAGE DISPOSAL <br /> <br />RETURN TO; <br />Marion County Health Department <br />3180 Center St, NE, Room 220 <br />Salem, Oregon 97301 <br /> <br />FEE SCHEDULE: <br />Non-refundable $37.50 per lot <br />to be submitted with <br />application. <br /> <br /> DESCRIPT%ON OF PARCEL (Attach Plot Plan as Exhibit A) <br /> <br /> FROPOSED USE OF PARCEL (NU~ER OF H6MES~TESp AND LOT S%ZE(S): <br /> <br /> If for a commercial business o= restaurant, we ~eed to know the n~er of employees and/ <br /> or the seating capacity: .. <br /> PRESENTLY DESI~ATED L~ ~B, ZONI~q.,. ~D N~ OF DES~ATING~CY: ... <br /> ~fEST HOLE RE~T~M~NTS: <br />'~e }{omesite. You will nor need to dig ~est holes unless notified. ~r~ <br /> ~o or More ~tome~ites: ~o test holes mnmt be prepared on each parcel, 2 ft. by 3 ft. wi~e <br /> and 4 ft. deep, and 75 ft. apart in the proposed areas. <br /> Test holes ( ) have been prepared ( ) will be prepared by __ <br /> (date) <br /> ~IS REPORT %S NOT A PE~IT. It does no~ eliminate the need for required plan~%isg <br /> sion approval, building, or location permits. <br /> <br />I HEREBY REQUEST FROM THE DEPARTMENT OF ENV%RONMENTAL QUALI%~ A STATEMENT OF FEAS%BILITY <br />'mE ABOVE PlEateD OF SEWAGE/_o/~D!SPOSAL FOR THE ABOVE DESCR:BED PARCEL.~/ ~~ <br />Name of Applicant ~Oi~_~_~__O~j~_/ Signature of Applicant ..... - <br /> ! <br />Address of Applicant ~2e ~/~f ~ %~ ~- ' Title Owner, Buyer, Agent <br /> <br /> (for DEQ or Agen~ use only) ~-- ~ <br /> <br />Conm~ents and recommendations based on Subsurface Site Investigation by DEQ or Contract Age~ <br /> <br />Soil is similar to Nekia silty clay loam. Silty clay at 24". <br /> <br />Approved pending acceptable plot plan prior to construction. <br /> <br />Agent .. Mari~ Con, tv . Signature . Date ~- X- 2./ <br /> <br /> Sta~e~ent of D~Q/Contract Agent Relative to Above Application <br />(~/The above described method of sewage disposal is ~pproved subject to the following <br /> conditions: <br /> <br />( ) The above described method of sewage disposal is not approved for the fot3owing rsasoo <br /> <br /> 'or E /Co r ct A - <br /> g- -. ~ ~te ~-7 7-/ <br /> <br />51t-50 Rev. 11/76 <br /> <br /> <br />