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Env~ro~u~l Rsal~h $~rv~ce~ Division <br /> <br />S~ Oregon 97301 (588-53~6)~ agent for: <br />Depar~t o: ~vi~o~u~l ~ity <br /> <br />To be submitted with application for <br />bu/ldtng per~Lt or mobile hom~ place- <br />ment permit. <br /> <br />Permit Fe~: NeW - $75.00 ($37.50 with site evaluation) <br /> <br /> Reps!!, Replace,: Air,rat.ion - $25.00 <br /> <br />tLEF~CE INFORHATION <br /> <br /> Viola K~kow <br />Name o£ Applicant <br /> <br /> G223 We~t ~taytOn <br /> <br />City, State~ Zip ~e <br /> <br />Sectiou / .... T~p ~ l~e ~ <br /> <br />Tax Lot or Account ~ ........ <br /> <br /> 3 acre8 <br />Lot Size <br /> <br /> 9223 ~est ~tay~o~ Rd. ,~ummville <br />laroper~y Address <br /> <br />Si:e ~val~ation seria~ Nmaber <br /> <br />'~talle~'s Na=e <br /> <br />Installationwill serve: <br /> <br />Building .. <br /> <br /> Repair <br /> <br /> House., Flobile Home x Mobile Home Park <br /> <br />. . OCher (explain) ...... .. Replace <br /> <br />Number of Ll~lag ~uit$ <br /> <br /> 3 bedroom <br />N%~her of Bedrooms <br /> <br />Water Supply; Public ~, Co.unity Private__Garba&e Disposal? no <br /> <br />i. Proposed Subsurface Sewage Disposal System Plot P!a~ <br /> <br />2. Pl~--lng Bvalua£ion -- Bu/lding Permit <br /> <br />3. Building Pi~ <br /> <br />hereby c~rttfy =hac ~he info~mation contained i~ this application is true and correc~ <br />to ~he ~sC of ~k~led&e ~d belief. <br /> <br />rev. 12/76 <br /> <br /> <br />