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Marion Oounty I~{ of Public l{eail:h~ ,-'T6 b~ ~%t~mitted with application <br />S~l~m, Ore~ 97~21 (~88~5346), agent for: ~,tlding permit or mobile hczne <br /> <br />Applicatioa to the D~t of E~viro~me~ta~ ~,~]ity <br />for a Pemmtt to O~truct a Ne~ ~r ~ <br /> <br />Pe~it Fee~: N_.e~_ - $50.00 ($2~5.00 with site evalu~tion) <br /> <br />,,,/j <br /> <br />Tax lot or Account <br /> <br />'Ins~aller'~ N~ "' <br /> <br />(k,m~rcial B~llding O~her (eX~iain) __ <br /> <br />Numbar of Living Uni~ ,,, ~ of Bedrocms _ <br /> <br />Garbage Disposal? <br /> <br />Water ~pply: Public. <br /> <br />2. Planning Ev~luati~ -- Building Permit <br /> <br />3. Building Plans <br /> <br />I h~reby cer'cify that She information contained in this ~pplication is true and correct <br /> <br />to the best of r~ knowledge and belief. <br /> <br />~I-57 7/74 <br /> <br />Si~mture (owaer/instalier) <br /> <br />'~te ' ' ...... <br /> <br /> <br />