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EnvirO~mental Health Services Division <br />Marion County Depaztlment of Public Health <br />Salem,, Oregon 97301 (588-5346), agent for: <br />Department of En¥iroua~tal QuaIity <br /> <br />building peZ'm~t or mobile home place- <br />ment <br /> <br />Applicatio~ to the Department Of Environmental Quali=y <br />for a Permit to'Con~t~U¢~ a Ne~ o~'Rep~i,r <br /> <br />Permit Fees: New - $75.00 ($37.50 with site evaluation) <br /> <br />Repairt'?epl~cei'Alt~mcion - $25.00 <br /> <br />P. EF FA%EN CE INFORMATION <br />Name of Appliean~ <br />Mailing Address <br /> <br />City. State, Zip Code <br /> <br />Site Evaluation Serial N~mher <br /> <br />Seetion~ Twp'~ ~ Rge / ~ <br /> <br />Tax Lot or Account <br /> <br />P~operty Address <br /> <br />Instate <br /> <br /> ~RAL DESCRIPTION <br /> New Construction __ Repair <br /> <br /> Installation will ~erva: ~ouse' /~ Mobile Home' <br /> <br />Commercial Building__ Other (explain) <br /> <br />N~ber of Living Uni~ <br /> <br />Water Supply: Public ~ Co.unity <br /> <br /> __Mobile Home Park <br /> <br />.... Number of Bedrooms ~/ <br />Private~'Garbage Disposal? <br /> <br />1. Proposed Subsurface Sewage Disposal System Plot <br /> <br />2, Planning Evaluation -- Building <br /> <br />3. Building Plan~ <br /> <br />Per.it No. ~ ~ <br /> <br />Issued __ ~-'~- 2]) <br /> <br />I hereby certify Shau the information contained in this application is true and eorreo~ <br />~o the best of my knowledge and belief, <br /> <br /> Signature .... ~" ' ' ' <br /> <br />rev. 12/76 <br /> <br />Date <br /> <br /> <br />