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Enviror~nental tIealth Services Division <br />~rion County Department of Public Health <br />Sal~, Oregon 97301 (588-5346), agent for: <br />Dep~rtmeut of Environmental Quality <br /> <br />To be submitted with application for <br />building, permit or mobile hc~e place- <br />ment permit. <br /> <br />Application to the Department of Environmental Quality <br /> for a Permit to Construct a N~w or <br /> a Sttbsurf~ce Sewage Disposal System <br /> <br />Permit F¢~,s: New - $50.00 ($25.00 with site evaluation) <br /> <br />Re~pair~ Alteration - $15.00 <br /> <br />~CE iNFORMATION <br /> <br />N~ of Applicant <br /> <br />~.~iling Ad,ess <br /> <br />Section <br /> <br />Tax Lot or Account # <br /> <br />Property ~xtdress <br /> <br />B. GENERf~L DESCRIPTION <br /> <br />New Construction <br /> <br />Installation will serve: <br /> <br />Coaw~rcial Building <br /> <br />Numbe~ of Living Units <br /> <br />Water ,~upply: Public <br /> <br />Installer's Name <br /> <br /> Repair <br /> <br /> House Nobile Hc~o ~/;~obile Home P~rk <br /> <br />__ Other (explain) <br /> / Number of Bedrooms ~ <br /> __ Ca~mmity P~ivate L/~b~ Disposal? <br /> <br />C. REQUIRED EYe!BITS <br /> 1. Proposed Subsurface Sewage Disposal System Plot Plan <br /> <br /> 2. Planning Evaluation -- Building Permit <br /> <br /> 3. Building Plans <br /> <br />I hereby ~ertify that the information contained i~'this ~lication is:~l'u/d/d"corrcet <br /> <br /> ~ _ / Si~urC (owne~f~i~s~Wier) <br /> <br />E~I-57 7/74 I~%te / / <br /> <br /> <br />