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HomeMy WebLinkAboutPermit Septic Tank 1994-5-24 ~ ( , i '" " " REQUEST FOR: , SEPTIC SYSTEM AUTHORIZATION , TO/oNSHlP 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 I r1.C.4-4<<6 C! jerq--r .p r LhJ fre""" NO. OF BEDROClIAS ~ bJ.--.s f.o ~- i3J...- APPLICANT NAME & ADDRESS PAUL CROOSE, SAME AS THE JOB ADDRESS ABOVE PHONE 747-8710 PHONE 687-4221 PHONE 746-5063 2lP J is true and correct DATE ,~ 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 ---- r. . FEES DUE: ~ Jl.""~ .""........... $ APPROVED BY: DATE .~. ..~. ~ ~ 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. , ~7iiW ;/115 Ac;rP?#,v.