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Marion Coun2y Department of Public Health <br />Salem, Oregon 97301 (5S8-5346)s agent for: <br />Department of ~-viro~m~ental Quality <br /> <br />To be submitted with application for <br />building per. dr or mobile home place- <br />~ent permit. <br /> <br />Appltcatto~ to the DegarCment of F, nvironme~tO1 Q~altty <br /> for a Permit toU6n~t~uc~t a New <br /> a Subsurface Sewage Disposal System <br /> <br />Permit Fees: New- $75,00 ($37.50 with site evaluation) <br /> <br />R~pair, ~Replace, A/t&~_a_~io~- $25,00 <br /> <br />A.' ~F~ENCE.INFORMATI~ <br /> <br /> Ns~ of Appiica~ <br /> <br /> ~tliug Addres~ <br /> <br /> ~itY,"S~te, Zip Code <br /> <br />Se. ct/on Twp',,,, Rge <br /> <br />Tax Lo~ or Account # <br /> <br />Lot Size <br /> <br />P~operty Address <br /> <br />site E%aiu'~t'ken Serial <br /> <br />New Construction , <br /> <br />~estal!attoe will serve: House'~Mobile Ho~e' <br /> <br />Comme=¢ial ~uildtng__~__Other (ex~lalu) <br /> <br />Number of Living Units ,,,, ;/ <br /> <br />Water Supply: Public <br /> <br />C. REQUI~ED EXHIBITS · <br /> <br />,Mobile Home Park <br /> <br />Commuafty ..... <br /> <br />· Private Garbage Disposal? ~ , / -' <br /> <br />1. Proposed Subsurface Sewage Disposal System Plot P%an <br /> <br />~- Plar~ninE Evaluation -- Bu~ldin~ 2erm~t <br /> <br />3, Building Plans <br /> <br />Perm/t No. ~.~..~ <br /> <br />EH-57 rev. 12/76 <br /> <br />I hereby certify that the information contained in ~his application is true and correct <br />to the best of 'my knowledge and belief. <br /> <br /> <br />