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Eavirorn~ntal Health ~)rvioe~ Division <br />Marion Cotmty ~eparUment of Public <br />Sa/em, Oregoa 97301 (f~9-5346), ag~aZ for: <br /> <br />To be submitted with applieatioa for <br />build~ permit or mobile ho~e plaoe- <br />m~At <br /> <br /> A~01ic~tion to the Department of Envirom~e~tal Qm~lity <br /> fo~ a Permit to Om~struct ~ Ne~ or Repal~ <br /> <br />Peal~lt Fe~$: ~evX - $50.00 ~.~.~th site ev~l~tiO~) <br /> Repair, Alter~tio~ - $15.00 <br /> <br />Nan~ o~ Applicant <br /> <br />C&ty, Stat~, 'Zip ~ <br /> <br />tq¢ zL. l <br /> <br />G~ERAL E~ScRn~rz~ <br />N~ Construction ~ <br /> <br />In~t~llatio~ will s~rve: House <br /> <br />~-blle IIc~e P~rk <br /> <br />1. ~ Subsurface Sewage Disposal System Plo~ Plan <br /> <br />2. Planning E~zaluation ~ ~,~nE ~t <br /> <br />3. ~ng Pl~ <br /> <br />hereby e~a~ify that the inf~mztiau co~t~in~d in this ~pplication is true and correct <br /> <br />to the be~ Of a%, know-ledge and belief. <br /> <br />I~-57 7~74 <br /> <br />Mlg~ture (o~er~ler) <br /> <br /> <br />