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Envt.ro~mental Health Services Divisio~ <br /> <br /> Oregon 97301 (S88~5346), aEent <br />Departmen~ of ZnvlToram~ntal Quality <br /> <br />To be submitted wl~h application for <br />building permit or mobile home place- <br />memt pe.~mit. <br /> <br />Application ~o th~ Department of F~nvfremmental Qua%try <br />for a Permit to Ctras~rUCt a N~w orRe~...air <br />a Subsurface Sewage Dispo$~t System <br /> <br />Permit Fees: New - $75.00 ($37.~0 with site evaluation) <br /> <br />Repair, Repla~a, Al~raCSpn - $25.00 <br /> <br />Name of Applicant <br /> <br />C~y, S~ate, Zi~ Code <br /> <br />Site Evaluation Serial <br /> <br /> Address <br /> <br />installer'e <br /> <br />B. ~ENERAL DESCRIPTION <br /> <br /> %nstalletion will serve: <br /> Commercial Building <br /> Number of Living Unit~ ~ <br /> Water Supply: Public <br /> <br />C. R__~L~R__ED EX~I BITS <br /> <br />House .... c~/Mob ils Home <br /> <br />Mobile Home Park ...... <br /> <br /> Other (explain) <br /> <br /> / ~umber of Bedrooms <br /> <br />..... Community ~ P~ivate/ Garbage Disposal? ...~, <br /> <br />]. Proposed Subsurface Sewage Disposal System Plot Plan <br /> <br />2. Plannl. og Evaluation -- Building Perzmit <br /> <br />3. Building Plans <br /> <br />I hereby certify that the informa~to~ Contained in this ap~lica~ien is true add correct <br />tO the be$~ of my knowledge and belief. ~ ('~ ~ ,~ t ~ <br /> <br />g}I-57 rev. 12/76 Date <br /> <br /> <br />