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, EnvirOnmental Health Services Division <br /> )iarion County Department of Public Itealth <br /> S~l~Jn, Ore~on 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 />merit <br /> <br />Application to the Department of Envirorm~ental Quality <br />for a Permit to Construct a New or R~ai~r <br />a Subsurface Sewage D';~°sal Syst~_ra <br /> <br />Permit Fc~s: I~w - $50.00 ($25.00 with site evaluation) <br /> <br />Repair~ 41terat..i0n - $15.00 <br /> <br />Name of Applicant <br /> <br />N~ilin~ Addmess <br /> Ora- <br />City, State, ~ip ~e <br /> <br />Section <br /> <br />Tax Lot or Account # <br /> <br />Lot Size <br /> <br /> / <br />Property Address <br /> <br />B, GFA~tqAL DESCRIPTICN <br /> <br />New C~nstruction <br /> <br />Installer's Name <br /> <br />Repair <br /> <br />Installation will serve: <br /> <br />Com~rcialBuilding__ <br /> <br />Number of Living Units <br /> <br />Water Supply: Public <br /> <br />House ~obile ~ ~ Mobile IRene Psmk <br />Other <br />/ ~r <br />C~ity Pri~te <br /> <br />C. ,R~. UIR~D EXHIBITS <br /> <br />1. Proposed Subsurface SewagoDi~al System Plot Plan <br /> <br />2. Planning Evaluation -- Buildin~ Permit <br /> <br />3. Building Plans <br /> <br />I hereby certify that the info,rm~, tion contained in ~his application ~ true and correct <br />to the bes't of my knowl~e ,and oelief. ,,~//; ' ~ ~.~.~ /~-_ . / <br /> <br /> :f,.,,, <br /> S~at~e (o~er/inst~er) <br /> <br />~I-57 7/7~ <br /> <br /> <br />