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Marion County Department of l~ublla Health <br />Salem, O~egoU 97301 ($88-5346), a~en~ fo~ <br />Depa~t~mt of En~i~O~o~al Qualf~y <br /> <br />To be s~bmittsd with application for <br />b~ilding permit or mobile home place- <br />ment permit, <br /> <br />for e Permit to Construct,, a N6~e or Repair <br />a ~baurfaae Sewage Disposal System <br /> <br />New - $?$.00 ($37.50 with si~e evaluation) <br /> <br />Belair, ~?.LaCe, .A~tir.d~i~n - $~.00 <br /> <br />REFERBNCI~ INFORMATION <br /> <br /> Address <br /> <br /> S~ate, Z~ C~de <br /> <br />Evaluation Serial Number <br /> <br />Tax Lot or Accotmt ~ <br /> <br />Install~ion will serve: <br />Commercial Building <br />~mber of Lfvin~ ~n~Cs <br /> <br /> Repsif <br /> Mo~se /Mobile ~ome ....... Mobile Ho~e Park <br /> <br /> Other (explain) <br /> · N~er of Bedro0l~ <br />__ Community .... Private~ Garage Disposal? .,/~ <br /> <br />i. Proposed Subsurface Sewage Disposal System Plot Plan <br /> <br />l. Plar~ning Evaluation -~ Building Permit <br /> <br />Ht~57 rev. 12/76 <br /> <br />the best of ~ k~ledge ~d belief. <br /> <br /> <br />