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E~vl~ental Health ~vio~s Division <br />g~rion O0unty Departme~ of Public He~Lth <br />Sadam, Or~g~u ~7301 (58~), ~e~t ~or: <br /> <br />To be ~%~b~ti$ix~d with ~4Y~licatiou for <br />building permit or mobile 1~ place- <br /> <br />~4~plica~ion to the I~artment of Env~tal Q~alit¥ <br />for a P~rmit ~o Construct a New 0~ p~ir <br />a Subsurface ~sposal Sy~t~ <br /> <br />Pon'nit F~S: N~ - $50.00 ($25,00 with sl~e evaluation) <br /> <br />P~o 'azr ~teration - $15.00 <br /> <br />Nam~ of Am)ll,.~% <br /> 4712Libbey <br /> 8991 Edclif~ Ct. gE <br /> <br /> Salem <br /> <br />CitY,'~tat~, Zip'~le <br /> <br />Sectica <br /> <br />12 & 13 <br /> <br />T 8 <br /> <br />T~x Lot or Account # <br /> <br />Lot Size irregular <br /> <br />8991Edcliff SE <br /> <br />Property Address <br /> <br />Installer' s N~ne <br /> <br />B. 'CiW~AL DESCRIPTI~ <br /> <br />New Construction <br /> <br />Ir~tallation will ~rve: }louse <br /> <br />x l~bileRm~e <br /> <br />Mobile NcmeP~k <br /> <br />Cannercial Building <br /> <br />__ other (ex, lain) ....... <br /> <br />NurSer of LivingUnits <br /> <br />~ber of P~,~L~x~s 3 <br /> <br />Water .~9upply: Public__Community__ Private__ <br /> <br />Garbage Disposal? yes <br /> <br />C. ~RE9 /ZHIBtT8 <br /> <br />1. Propose~ Sabsur£aco S~vage Disposal Systmm Plot Plan <br /> <br />2. Planning Evaluation ~ BuLlding Permit <br /> <br />3. ~uildlr~.~, <br /> <br /> <br />