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Eavirommental Health Services Division <br /> County D~paa~m~nt of Public Ha~lth <br /> Oregon 9~301 (888-~), agent for: <br />~p~gmant of Envirommauta/ ~it~ <br /> <br />TO be m~mit~ed with ~pplication for <br />building pextait or m~bile home place- <br /> <br />Application to the Department of Eavironmautal Quality <br />for a Petmi~ to Oan~ a N~ or ~ <br /> <br />Permit re~: Ne~ - $50.00 ($:25.00 with $1~e ev~luatioa) <br /> <br /> K_enneth Boc~e (Jer~y 8ooze) ~e(~tioa <br />~ne o Applican~ ' " <br /> <br />T. ,~ Rlw <br /> <br />4606 View C~est Rd. So~h <br /> l~Addrems <br /> <br />Salem, Oregon 97302 <br />[~cy, ate, Zip Code <br /> <br />Rt. l~ B~X 50~, Aurora <br /> <br />Ne~ Co--ion new,~, ~ <br />Inst~llatioa will ~--~e: House x ~obile ~J:me ~bXle ~ ~ <br /> <br />1. Px~pO~ Subsurface Se~mge Disposal S~ Plot <br /> <br />2. P~u~ Evaluatiou -- t~,~Idimg Pemit <br /> <br />I hereby oar~lfy that the iufommatiou c~mf~%ine(l in ~h!~ applioati~ is true and ~t <br />to The be~rc of m~ k~owledge amd belief. <br /> <br />Perrait No. (~ CD <br /> <br />7/7 <br /> <br />sig~ (o~er/~ler) 0 <br /> 2/4/76 <br /> <br /> <br />