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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 Quality <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 Rep~iK <br /> a Subsurface Sewage Disposal System <br /> <br />Permit Fees: New - $75.00 ($37.50 with site evaluation) <br /> <br />~e~a~r, Replace, Alteration - $25.00 <br /> <br />~EFERENCE INFORMATION <br /> <br />N~e of F4~plicant <br /> <br />Mailing Address ~3 <br /> <br />Site Evaluation Serial Number <br /> <br />Section /y Twp ~ Rge <br /> <br />Tax Lot or Account # <br /> <br />Lot Size /O , <br /> <br />Property Address <br /> <br />Installer's Name <br /> <br />GENERAL DESCRIPTION <br /> <br />New Coastruction <br /> <br />Installation will serve: House <br /> <br /> Repair <br />/Mobite Home <br /> <br />Mobile Home Park <br /> <br />Commercial Building <br /> <br />Nember of Living Units <br /> <br />Water Supply: Public <br /> <br />RE UIRED EXHIBITS <br /> <br />__Other (explain) <br /> · <br /> __ Community__ <br /> <br /> Number of Bedrooms ~ <br />Private / Garbage Disposal? ~- <br /> <br />I. Proposed Subsurface Sewage Disposal System Plot Plan <br /> <br />2. PlanninK Evaluation -- Building Permit <br /> <br />3. Building Plam$ <br /> <br />I hereby certify that the information contained in this application is true and correct <br /> <br />to the best of my knowledge and belief. <br />Per,it No. qO~ <br /> <br />~{~57 rev. 12/76 <br /> <br />Signature <br /> <br /> <br />