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., ', ?.STATE'BT OF F~S~B~LI~ FOR PROPOSED SUBSU~A~E SEWAGE DISPOS.~ <br /> <br />RETURN TO: <br />Marion County Health Department <br />3180 Center St. NE, Room 220 <br />Salem~ Oregoa 97301 <br /> <br />DESCRIPTION OF PARCEL (Attach Plot Plan as Exhibit A) <br /> <br />FEE SCHEDULE: <br />Non-reftmdable $37,50 per lot <br />to be submitted with <br />application. <br /> <br />Section '5 ~_ ;Township _~__; Range~l County of~/~,~l , Oregonl Tax lot~-27/ <br />Narrative Demerlptfo~; .~ ~ ~ ~/- ~ ~_~ <br /> <br />If for a co~ercial business or restaurant, we need to kn~ the number of employees and/ <br />or the seating capacity: ~ <br /> <br />&":One I'le~r~.~s.it_~¢."~/ You will not need to dig test holes unless notified. <br /> l~o or"~f6~e Homesites. .[x,o test holes must be prepared on each parcel, 2 ft. by 3 ft. wide <br /> ~i~ £g~ deep, and 75 ft. apart in the proposed areas. <br /> Test holes ( ) have been prepared ( ) will be prepared by __ <br /> (da~e) <br /> THIS REPORT IS NOT A PERMIT. It does not eliminate the need for required planning coramis- <br /> sioo approval, building~ or location permits. <br /> <br />I HEREBY REQUEST FROM THE DEPARTMENT OF ENVIRONMENTAL QUALITY A STATEMENT OF FEASIBILITY <br />THE ABOVE MET%tOD OF SEWAGE DISPOSAL FOR THE ABOVE DESCRIBED PARCEL, <br /> <br />N~me of Applicant ~ ~ Signature of Applicant <br /> <br />Address of Applicant ~f2 ~r~x*.q2~ __ Title Owner, ~uye~t <br /> <br />************************************************************************ (for ~EQ or Agen~ use only) <br /> <br />Co.cots and recomendations Based on Subsurface Site investSgation By DBQ or Conrracg Age' <br /> <br />The soil on the property is similar to a Woodburn silt loa~. The property is approved <br />for one homesite on three (3) acres pending acceptable plot plans prior to any <br />construction. <br /> <br />"Present this evaluation when applying {of <br />building ' ~ <br /> perm~to. Fees {O~ %ndiviclual lots, <br />that are approved~may beapplied to permit <br /> <br /> date Signatu~ <br /> <br />Agent Marion County Signature <br /> <br /> Statement of DEQ/Contract Agent Relative to Above Application <br /> <br />( 9 The above described method o£ sew.age disposal is approved subject to the ~ollowing <br /> conditions: <br /> <br />( ) The above described method of sewage disposal is not approved for the following teaser <br /> <br />For the DEQ/Contract Agent . :~/~( ............... Date ,.~'-/,~ 2 7 S¢' <br /> <br /> <br />