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Oregon 97301 (588-5346)~ agen~ <br />Depar~t Of ~viro~n~l <br /> <br />To be submitted with application for <br />building permit or mobile hom~ place- <br />ment pe~m/t. <br /> <br />~plieation to ~he Depart~aent of ~nvironmen~al Quality <br />£or a Faceit to 'COnstruct a New or 'K~_~ <br />a Subsurface $6~age }i~posal System <br /> <br />Permit Fees: New - $75.00 ($37.50 with site evaluation) <br /> <br />Repair, <br /> <br />A..~m~NC~ <br /> <br /> Name of Applicant <br /> ,4 .... <br /> <br />New Cons~ruetion ..... <br />Inetalla~tou will serve: <br />Co~ercial Building <br />N~mber of Living Units <br />Water Supply: Public <br /> <br />Tax Lot or Account <br /> <br />P~oper ty Address <br /> <br /> ...... Repair_~ <br /> <br /> House',,,, ~T:" ~obile Home <br />. Other (eXplain) ..... <br /> <br />Mobile Home Park <br /> <br /> Number of Bedrooms ~_~,. <br />Private i/ Garbage Dlspossl? ~.~.~'s, <br /> <br />1. Proposed SubsurIace Sewage Disposal Sy~t6~ Plot Plan <br /> <br />3. Buildln~ Plans <br /> <br />to the best of 'my k~owledge and belief. <br />Perm/t No. ,,,, ,~?0. <br />Issued = <br /> <br />hereby cart/fy that the information contained in this application is tr~e and correct <br /> <br />~4-57 rev. 12/76 <br /> <br />Sig~ure <br /> <br />Date <br /> <br /> <br />