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~uvlron~en~al Realth Services ~)ivision <br /> <br />Salem, O:cel~OU 97301 ($88-53t6), agent for: <br />'~epert~e~[ o2 ~nviron~en~al quality <br /> <br />To be s~it~e~ with ~pplication <br />bulldln~ permit or mobile ho~e place~ <br />men~ <br /> <br />Appltcaticra to ~he Department of F~virotlmen~l Qtmlity <br /> for a Ve~i~ to Couse~uec a ~ew o~_~pair <br /> a Subgurfece Sewage Disposal <br /> <br />$75,00 ($37.50 ~i~h si[e eveluatto~l) <br /> <br /> Y. A. Mix <br />Name o2 Appl~c~ <br /> <br />3497 Abra~ N. E. <br /> <br />Salem, Oregon 97303_ <br />Cl~y, ~l-ate, Zip Code <br /> <br />Tax [,et or icco~uL # .., <br /> <br />Lot gize 20. ac~es <br /> <br />10955 Mix R~, S. E.~ AuMs~ille <br />Proper~yAddrees <br /> <br />GEN ~/t~L DESCRIPTION <br /> <br />New COnStrue £iom <br /> <br />InstallaTion ~11 se~e: House". <br /> <br /> in/teller's' ~a~e ........ <br /> <br />~obile lio~te ~xx Mobile Ho~ Perk <br /> <br />Co~zae~cial bulldin~ .... Other (explain) <br />Number of Living Units 1 Ntaabe~ of ~edroo-e 2 <br /> <br />Water Supply: Public. <br /> <br />Co~-uni£y____Privete ...~ <br /> <br />_ .. Garbage DispOsal? no <br /> <br />1. Proposed g~bsurface $~age Disposal System FIO~ Plan <br /> <br />2. Pla~in~ Evalue~ion -- Bulldi~ Pet~it <br /> <br />3. ~uildlmg Plans <br /> <br /> hereby certify thai ~he infol~mtion contained l~l this applleati(~l is true and correc~ <br />to the best O~ ~ k~o~l~ge ~nd belief. <br /> <br />Pe~i~ No. ~ <br /> <br />EH-5? raw 12/76 <br /> <br />Date ........ <br /> <br /> <br />