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Depaxtm~n: of Environmental Quality <br />1234 S. w. Morri~n <br />Poxtland, Oxmgon 97205 <br /> <br />Applicati~n to the Department of En~lro~mene~1 Quality <br /> <br /> for a Permit to ~on~truc~t a <br /> <br /> New or Re~a~r_ a Subsurface Sewage <br /> <br /> Disposal Syste~ ~ <br /> <br />DESCRIPTION <br /> <br />New Construction <br /> <br />Installation will serve= ~ouse ~ .. Mobile Ho~e_...__~ile A~me Park <br /> <br />C~mmer=ial Su/ldimg <br /> <br />Other (F~plain) <br /> <br />NO. of Living U~its__~ No. Bedrooms <br /> <br />Water Supply: Public X ~ Cc~muntty Private <br /> <br />Gar~3'e Disposal? <br /> <br />c. ~QUIR~D EXHIBITS <br /> <br />Proposed Subsurface SeWage <br /> <br />Planning EValuation - Building Permit ~a! O~t~oR) ........ <br />Other (Local O~tton)~il~in§ Plan~ <br /> <br />I hereby =ertify that the information o~ntained in this a~l£cat~~ i~ t~l~e ~ <br />correct eo ~/~e best 0£ ~y k~oWl~ge anc~ belie£. <br /> <br /> Signature (Owner/Inatailex) { <br /> <br />Interim Form <br /> <br /> <br />