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En¥iro~me~tal ~ealth Services Division <br />Marion County Department of Public'Health <br />Salem, Oregon 97301 (588-5346), agent for: <br />Departmemt 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 Q~ality <br />for a Permit to..~pn.str.uct a New or'Repair <br />a Subsurface Sewage Disposal System <br /> <br />Permit Fees: N__~- $75.00 ($37.50 with site evaluation) <br /> <br />Re~air,'~eplaee,'Alteration - $25.00 <br /> <br />A. REFERENCE INFORMATION <br /> <br />Name of Applicant <br /> <br />po 3ox 288 <br />Mailin$ Address <br /> <br /> :'kuln~:vJtle <br />City, State, Zip Code <br /> <br />Tax Lot or Account # <br /> <br />Lot Size 2 acres <br /> <br /> 7243 Shaw llighway E,e, &umsville <br /> <br />Property Address <br /> <br />Site Evaluation Serial Numbe~ 'Installer's Name <br /> <br />GENERAL DESCRIPTION <br /> <br />New Construction <br /> <br />x Repair ................ <br /> <br />Installation will serve: Mouse x Mobile Eome <br /> <br />Mobile Home Park <br /> <br />Commercial Building <br /> <br />Number of Living Unit~ <br /> <br />___ Other (explain) <br /> <br />iiou:;e has burned - buzl~zn~ r,e,~ <br /> re?['~ce thor ' -- <br /> Number of Bedrooms 3 bedroom <br /> <br />Water Supply: Public ...... Co~unity__Private~Garbage Disposal? <br /> <br />C. R~QUIRED EXHIBITS <br /> <br />1. Proposed Subsurface Sewage Disposal System Plot Plan <br /> <br />2. Planning Evaluation -- Building Permit <br /> <br />3. Building Plans <br /> <br /> is true and correct <br />I her eby certify that the information contained t~s ~-' ~ // <br />to the best of'my ~nowledge and belief. ~ /'~ applicatSon <br /> <br /> Date <br />EH-5? rev. 12/76 <br /> <br /> <br />