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Environmsntal Health Services Division <br />Marion County Department of Publia Health <br />Salem, Oregon 97301 (588-5346), agent for: <br />Department of Envirom~ental 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 o= Re_~pair <br />a Subsurface Sewage Disposal System <br /> <br />Permit Fees: ~,~w - $75.00 ($37.50 with site evaluation) <br /> <br />~ep,air, Replace~,,.A,l,~gr~,ion - $25.00 <br /> <br />A. REFERENCE INFOKMATION <br /> <br />Section /~ Twp <br /> <br />Tax Lot or Account # <br /> <br />Lot Size 1 <br /> <br />Installer~s Name <br /> <br />Name of Applicant <br /> <br /> 11653 Pacific C<~urt N. E. <br />Mailing Address <br /> <br /> Wo<~dburn~ (~r~qon 97071 <br />City, State, Zip Code <br /> <br /> 9-76-7 <br />Site Evaluation Serial Number <br /> <br />B. G~NgRAL DESCRIPTION <br /> <br />Repair <br /> <br />New Construction xx <br /> <br /> House x× Mobile Home <br />__Other (explain) <br /> <br /> 1 <br /> <br />Community__ <br /> <br />Mobile Home Park <br /> <br /> Number of Bedrooms 3 <br />Private xx Garbage Disposal? <br /> <br />Proposed Subsurface Sewage Disposal System Plot Plan <br /> <br />Flaraaing Evaluation -- Building Permit <br /> <br />Building Plans <br /> <br />Installation will serve: <br />Com~aercial Building <br />Number of Living Units <br />Water Supply: Public <br />REQUIRED EXHIBITS <br /> <br />1, <br /> <br />2. <br /> <br />3. <br /> <br /> hereby certify that the information contained in this application is true and correct <br />to the best of my knowledge and belief. <br /> <br /> Date <br />EH-57 rev. 12/76 <br /> <br /> <br />