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.~~tal Health <br />~ion (b%mty Department of Public <br />Salem, Ore~m 9730~ <br />Dep~-bam'~ of Environmental Q,.:~.~ <br /> <br />To be sube~tted with applicatiom for <br />bulldi~ permit or mobile home place- <br />m~mt .p~t. <br /> <br />Applic~tio~ to the Depart of <br /> for a Permit to Construct a New or P~ai~ <br /> <br />PermitF~: <br /> <br />~antac6sral. Church of <br />]Tame of ApPlican~ " <br /> <br /> Rt. 1 8ox 28 B <br /> <br />Aum~v i 11 e ~, Q ~ego~ ,,, <br />~ity, k~te, Zip ~ <br /> <br />$.50.00 ($25. ~evaluation) <br /> <br />,. . ,,[5 / <br /> <br />Rt. i BoX 28 B Aumsvil~e <br />Property A~ires~ .......... <br /> <br />~ R <br /> <br />/ %) <br /> <br />Name ....... <br /> <br />New Coostruction <br /> <br />Installatio~ will ~ve: House ...... <br /> <br />MobLle ~ ~ Mobile <br /> <br />NLm~ar of Living Uuits . / :. Number of Bedrocx~ ~'~ <br /> <br />W~:er SUpply: Public .. Ccm~ity __ Priva:e ........ ~ Disposal? <br /> <br />1. Proposed Subsurface Sewage Disposal System Plo~ Plum <br /> <br />9.. Planning Eva/uation -- Building l~.rmi: <br /> Building Plans <br /> <br />I hereby ~ify that ~he infox~tio~ contained in this application is ~;~ and correct <br />to th~ be~; of m~ knowledge a~i belief. <br /> <br /> <br />