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Marion County Departmen~ of Public Health <br />Salem~ Oregon 97301 (588-5346), e~ent for: <br />Department of EuvironmenZal Quality <br /> <br />ment perm/t. <br /> <br />Application to the Department of Envtrenmen~al Quality <br /> for a Permit to Con$Sruct & New <br /> a Subsurface Sewage Disposal System <br /> <br />Per=it Feee: ~9~ - $75.00 ($37.50 wiuh site evaluation) <br /> <br />~gPa!r, Replac~,...A~.Kgx~t.~o~ - $25.00 <br /> <br />REFERENCE INFOP~ATION <br /> <br />Name of Applicant <br /> <br />Mailing Address <br /> <br /> Wo<>dburn, Or:.,on 97071 <br />City, State, Zip Code <br /> <br />9-7b-7 <br /> <br />B. G~NF/~AL DE__.$.~RIPTION <br /> <br />LOt 8iz~ 1 o~,re <br /> <br />In~ galier ' s Name : <br /> <br />New Consrru~tlon xx ..... Repair <br /> <br />Installation will serve: Ho~se x× Mobile Home <br />Commercial Building ..... Other (explain) <br />Number of Livfn$ UDits 1 <br /> <br />Mobile Home Park <br /> <br /> Number of Bedroom~ 3 <br /> <br />Privat~ wx~.Garbage Disposal? ve~ <br /> <br />Proposed Subsurface Se~a§e Disposal System Plot Plan <br />Planning Evaluation -- Bufldin~ Pe~t <br /> <br />Building Plans <br /> <br />I hereby certify ~hat the information contained in this application ia true and correct <br />to the beat of my knowledse and belief. <br /> .... ,, <br /> <br />K~-57 rev. 12/76 <br /> <br /> <br />