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~nviroru~n~al Health SerVices Division <br /> County Department of P~lfc H~alth <br /> 0regen 97301 ($88-53&6), a~t for= <br />Department of Envirom~ental Quality <br /> <br />To be submit:ed with applicat~on for <br />Building pe~ml£ or mobile home plece~ <br /> <br />Appllcatio~ to the Departmeu~ oi Fa~vironmen~al Quality <br /> ~or a Far. it to~Construs~a Ne~ or~e__~p.~ai~r <br /> a Subsurface S~ag6 Disposal System <br /> <br />Permit Fees: N~.~ -~ (~llNl~-with Sirs evaluation) <br /> <br />Repair, Replace.,.~a~aciou - $25.00 <br /> <br />RLTERF. NC ,~ INFORHATION <br /> <br />t~ailing Address <br /> <br />City, State, Zip Co~ <br /> <br />Tax Lot or Account ~ .... <br /> <br />Lot <br /> <br />Property AddressJ -~ <br /> <br />DESCRIPTION, <br /> <br />Installer~s <br /> <br />Installation will serve; <br /> <br />House~M~blle Home . Mobile Home_ Park <br /> <br />Go~mercial Building__ Other (e~lain) ...... <br /> <br />Number of Living Units ........ Number of Bedroo~ ~ <br />water S~pplT; Public --_ Community ~/~ Private Garbage DiSposal? <br />RE~I~ E~IB!TS <br /> <br />I. Proposed Subsurface Sewage Disposal SyStem Plot Plan <br /> <br />2. Planning ~valua~ton -- Building Permit <br /> <br />Building Plans <br /> <br />Permit No. <br />Issued <br /> <br /> hereby certify that the information contained in this application is true and correct <br />to the best Of my knc~ledge and belief. <br /> <br />~1-57 rev. 12/76 <br /> <br />Date <br /> <br /> <br />