HomeMy WebLinkAboutPermit Septic Tank 1995-12-8
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? "-2 I/qc- MUST BE IN BLACK...,1NK // form c55-11
Permit No. / <::J./ '1-{ .:/ Twnshp. -1-7 Range tJ-_"S Sectio~ C. "1 eCTax Lot --3 Ztl:1
Standard System ~Iternative S~te, m 0 (S,PnC~ TY"P,~ ,l _
Job Location (Street Address) --6?/ _!,2{/..czf/t~ ~ -' .7f/~
Supdivision/Partition # . Parcel Lot' Block
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DETAIL SYSTEM PLOT ~e~~N AS CON~!'~)1C.~~~ . "
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.1~\ljRONMENTA/.. HEAu :-',
USE BLACK INK ONLY
FOR INSTALLER'S USE: Trench Depth ~ lc if : - Gravel Depth Below Tile -h .
Tank Capacity ~ _ Manufacturer. JJ / A . , '
Measured Distance from Well to Tank ---.1fJiI:'r . From 6rainfield JfJ/A Total Length of Lines J!lb I
COMPLETE THE FOLLOWING IF A PUMP WAS USED ON THIS INSTALLATION:
I (installer's name) . certify that a (Mfg,) . (Model No.) Pump
and Mercury Float Switch (Mfg. and No.) have been installed with this sewage installation.
Signature . Date_
FOR SANITARIAN'S USE ONLY: ~. System Approved 0 System Disapproved
COMMENTS:
/J' ~,' A ~/l~~~, ected' DDaattee
System Capacity "'7~ gal./day Signature ~/V y;r
o Needs Correction
;~/~~/f ~- .
INSTAllATION RECORD & CERTIFICATE OF SATISFACTORY COMPLETION When signed by the County Sanitarian. this certificate is evi,
dence as per ORS 454,665 of satisfactory completion of a subsurface sewage disposal system at the above location.
To request inspection, return all three (3) copies of this form to: lane County Environmental Health Services, located in the basement of the
Public Service Building, 125 E. 8th Avenue. Eugene, OR 97401.