9835 SW INEZ STREET I
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9835 SW INEZ STRE'E'T' _
I
DEPAI TMUNT OF HHALTH AND HUMAN '7HRV.ICSS
ENVIRONMENTAL HEALTH AND SANITATION
APPLICATION FOR A PERMIT TO INSTALL AN ON-SITE SEWAGE DJSPOSAL SYSTEM
USE: New Construction fV Commercial/Industrial
71-1 PUNTMINC DEPARTMENT
Alteration El Other - VALIDATION
Repair r Comments. 4_/, ?<.tSc;< <s�'4.0.•t
�J
Residential
FV * Validation nct required Signed:
if site inspection appli-
cation validated les;. than
one year ago. --
Map and Tax Lot: Township Range /
KSection Tax Lo��
Owners Name
/Telephone l/
H
Address`„
Required Exhib'ts:
I. Three (3) copies (2 copies for a repair) of a correctly drawn plot plan
2. An approved site evaluation. (see attached)
3. **(Commercial/Industrial) An approved plan review fee.
**For commercial/industrial users, a plan review fee based on the projected daily sewage Clow,
will be charged. This fee (see OAR 340-71-140) is due at the time of permit application.
As the owner, his legally authorized representative, or his installer (licensed as required
under OR3 454.695), I certify the information contained in this application is complete and
accurate to the best of my k wI dge. I also understand that any inaccurate information may
invalidate constr ctioll a mit.
Signed---------2e/--- -- ---/ -_ __ Date "-'
-------------------------
For Environmental Health Uac_Cnlz:
Sewer Availability (distance from nearest canoe tion
point I.o nearest property line)
Type of System: — �~
Required --
-
Date Permit Issued (and fee received):
5E-15-rev. --- -- — ------_-
9/21/83 WCDPH