Laserfiche WebLink
E~WRONN~NTA~ ~ALT~ SERVICES D~IS~ON <br />De~t O~ ~viro~ental ~ality MAK~ON COU~Y DEPAB~NT OF PUBLIC <br /> 2455 ~NZEN S~T. <br />1234 S* W. Morri~on SAL~ ORE~N 97~01 - 588-5346 <br />Portland, Oregon 97205 <br /> <br />Land Quality <br />County <br /> <br />Application to the Department of Environmental Quality <br /> <br /> for a Permit to Construct a <br /> <br /> New or Repair a Subsurface Sewage <br /> <br /> Disposal System <br /> Permit Fees: ~ Repair, Alteration $15.00 <br /> $50°00 ($25.00 with site evaluation) <br /> <br />A. REFERENCE INFORMATION <br /> <br />Name of Applicant <br /> <br />City <br /> <br />B. GENERAL DESCRIPTION <br /> <br />Section <br /> <br />Tax Lot or Account #, <br />Lot size /. d/,~- 6~>e.,,~x~-~--~ ,, . ~ <br /> <br />Installers Name <br /> <br />New ConStruction <br /> <br />~e~afr <br /> <br />Installation will serVe: <br /> <br />Commercial Buildin~ <br /> <br />No. of Living units <br /> <br />House Mobile Nome Mobile Heme Park <br /> <br /> NO. Bedrooms <br /> <br />Water Supply: Public <br /> <br />Communit~ <br /> <br />Private / Garbage Disposal? <br /> <br /> ~UIREp EXHIBITS <br /> Plot"Pla~' <br />1. Proposed Subsurface Sewage Disposal System~ <br /> <br />2. Planning Evalug~ion - Building Permit (Local 9~tion) <br /> <br />3. Other (Local option) Building Plans <br /> <br />I hereby certify that the information contained in this application is true and <br />correct to the best of my knowledge and belief. '~ ~ <br /> <br />Permit No. ~ <br /> Date <br /> <br />Signature (Owner/Installer) <br /> <br />Date 0/ <br /> <br />Interim Form <br /> <br /> <br />