HomeMy WebLinkAboutPermit Septic Tank 1994-5-24
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REQUEST
FOR:
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SEPTIC SYSTEM AUTHORIZATION
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17
RANGE
03
SEena-/ 114SECTION
24.4.1
TAX LOT
3020
SUBOMSIOIII PARl1TION
LOT I PARCEL BLOCK
LOCATION ADDRESS
2764 BURLINTON AVE., SPRINGFIELD, OREGON 97477
STRUCTURES NOW ON PROPERTY
EXISTING SINGLE FAMILY DWELLING
PROPOSED USE SEPTIC NSTALLED
RESIDENTIAL USE
WATER INSTAu.ED
RAINBaV
NO. OF STORIES
NO. OF EMPLOYEES CONSTRUCTION COSTNAWE
DESCRII'1lCN OF PROPCSED WORK
SEPTIC SYSTEM AUTHORIZATION +0
DIRECTIONS TO SITE FROM NEAREST MAIN INTERSECTION
NORTH FRC11 28TH STtu::;bT AND YOLANDA
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NO. OF BEDROClIAS
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APPLICANT NAME & ADDRESS
PAUL CROOSE, SAME AS THE JOB ADDRESS ABOVE
PHONE
747-8710
PHONE
687-4221
PHONE
746-5063
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is true and correct
DATE
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OWNERS NAME & ADDRESS
SAME AS THE ABOVE
CONTRACTORIINSTALLEFVSUILDER NAME CCSI
THURSTON BUILDERS #97776
) ;AIL PE~MIT TO:
MAIL PERMIT TO THE OWNER AT THE JOB ADDRESS ABOVE
) NAME. STREET / mY
~ave ?retulIY read BOTH sides of this apPlic:a~n Jnd ~~Y 9>>"~Y that all information
~~ qROOSE ;1};f.;;f., /[A/ ~
, PRINT NAME $fgnsfure ----
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FEES DUE:
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APPROVED BY:
DATE
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LMD 040 Rev, 6/92
CALL FOR INSPECTIONS (SEE BACK OF FORM FOR INSTRUCTIONS) 687-4065
SEPTIC permits are good for one year. ALL other permits expire after 180 days unless Inspections are current.
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