HomeMy WebLinkAboutPermit Building 1974-2-8
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'\' : 'ei'\: , lANE COUNT~ jIL~N~<gERMIT OR MOBilE. HOl'. JSE PERMIT
~iJllDING~" MH D',' .; ".' ,: PERMIT NO. 93...714
PROPE'RTY OWNER MAILING. ADDRESS . ."
t:'O$tOV0!" '~V1struc~ fan. tCt!:90GlV .4~34 Moufl Spr.Jfl~fooVdt Oreg@n
CONTRACTOR MAILING ADDRESS.
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PROPERTY .LOCATlON - INCLUD'E POST"OFFICE
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2102 CCi1tQU'burv Si, -,SprhJ\ilHe(M
PROPERTY LEGAL DESCRIPTION - METES, BOUNDS
tDntarbtH~\1 .Vii 1G,90 lst"rSdtHt Dan
RANGE :SECTION
1,1
i7 03 ,.!. 2l}.<f./
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lot g...Ph.,>e1, -2
T~X LOT NO. CODE . CENSUS TRACT
i:P.::~' ',: 7 3t>z.R' 20Q~n 'ISO
EXISTING STRUCTURES ON PROPERTY~.,'::r
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Nane e'
LEGAL ACCESS TO PROPERTY
. Cant@rbilllr,y' St.;
'PROPERTY SIZE - FT.
WIDTH 7,!)~ 36 DEPTH 1 O~ I AREA
TWP
APPl.
NAME.
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MAILING
ADDRESS
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. FOR MOBILE HOME, PERMITS ONLY
No. . of . Bedroom~\ . \ ~
'STRUCTURES TO BE BUILT THIS PERMIT
~t.1~ 11\1 Vlt.! ' ", r~~' . /"\ \\.
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t10rQOO ., <9ti>~c~d .,c\i{uncolled
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Conn'ect to Existing Sewage System 0
TYPE CONSTRUCTION SQ. FT. # BDRMS
F r'im'e
15@2 @: 12 .
I
506 @. :3
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f.
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/Ltf
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p'HONE
7~1",S!)jJ
PHONE
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New System .D
VALUATION
19.62l:.
l~~ifl
19..5!j2 '...
. OTHERD
74.00
~o.~oo
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,PLUMBING INSTALLED BY
OWNERD OTHER: NAME tfoHvl.-g P'lumbnCll
WATER SUPPLY
'PUBLIC 0 '0 0rHER
. . SEWAGE DISPOSAL
. ,PUBLIC 0 SEPTIC TANK [!t]
BUILDiNG' ~.
WASTE DISPOSAL
PLUMBING
PLAN REVIEW
. PARK. TRAILER'
FEES
\.
TOTAL
t'; 11&". (bO .
COUNTY BUILDING & SANITATION
DRAIN FiElD REQUIRED
lIN. FT 150
OR SQ. FT.
SPECIFICATIONS
MIN. SEPTIC TANK CAPACITY
WITH DIS;-. BOX: GAl. 9dllO'
4
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TRENCH WIDTH FT.
. '\Re-dllndmnt. $ys-tcrim" re~ui i"~cl;;as i'err,.p lot.p libn.., .
...;
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TYPE'OF STRUCTURE
OCCUPANCY _ "
PUBlI<: UTll. EASE,MENl:.
OZONE
. . 5~~ '. ' l &:J .
BLDG. 'SETBACKS n FT. FROMCTR, OF ROAD RIGHT OF WAY
. US.E CLASSIFICATION
FRONT 40
REAR
, 7
SIDE INT. 5' SIDE EXT.
AUtHORIZED SIGNATURE - DATE
.. . './sl,J..t:'El0ss :bv. IC~' H8rb6u~h
, J~~Ii. \Sttt)Q>f{
3ee
DATE
2...8..-7 t;. s~l of
.f.
BLDG. PERMIT - WHITE
: 'OFFICE COPY -:- WHITE
COUNTY TAX - PINK
PLUMBING - CANARY
. BUilDING -'-.GREEN'
SANITATION _ GOLDENROD
. (
Construction. to. comply v,/ith unif.orm. building code and county regulations
covering plumbing arid sewage disposal. AII'buildings require a certificate
of occupancy. before being occupied.
'(Se1 Statement on Reverse ,Side)
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,,'-'FORM 'jf: C 55 - 13
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(POST THIS PERMIT ON MAIN, BLDG. AT SITE)
.,' .lANE COUNTY,BLDG;' &SAN..DIV", CbURT: HOUSE; EUGENE', OREGON 9740r-
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BUILDING.SiTE EVALUATION
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Building Permit Application No. 93-7Y
A1
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Tfl.~ -:;> S 2 f/ TAX LOT
CENSU~ .A~T .
farrterb,'rv Utll, Irtatld. L-'1 8-2
APPLI CANT: /
N/\ME.
ADDRESS
() Site Inspect ion
() Pre-Permit Investigation
PHONE
DATE
1-l-Y-7Y
,
I.
Zoning Ordinance Compl iance
(Zone...fi - ,L)
Subdivision Ordinanc~ Compl iance
NOT
app I icab I e
() ( )
( )
( )
( )
( )
NO
YES
NAME.
DATE
LANE COUNTY PLANNING DEPARTMENT
3.
4.
Required Access
( )
( )
( )
( )
<-~
(~
(~
(~ ~~~'.'J'.~
( )
1.. - ;;v1\""-7t/
2.
Building Site (Area, Width,
Frontage, Setback)
Other (see comments)
5.
COMM ENTS :
BUILOfNG INSPECTION SECTION NOT NO YES NAME DATE
apD I i cab I e ~
6. Plans Subm i tted ( ) ( )
7. Soil Stability (footings) )~ ( ) ( )
8. Flood Plain ~ ( ) ( )
)-, ) {)1t. A ~
9. Ot he r (see Comments) 9Q ( ) () e 't~~ " 2d~ -7Y
- r
COMMENTS: I
10. Sewage Disposal
NOT
aDD I icab I e
() ()
( ) ()
() ( )
( , ()
NO YES \~ \\
(t(\~~
(.(' (""
(f
DATE
SANITATION SECTION
~ -7 -71
II. Usable Area
12.. Water Supp I y
13. Other (see Comments)
( )
COMMENTS:
TO APPLI CANT:
. of Your Building Permit / Site Inspection:
f) --7 \7 (~ Can be app roved. '
~ () Cannot be approved at this time as indicated on item NO. above.
Questions and further information on items I through 5 contact the Lane-
COUNTY PLANNING DEPARTMENT. Questions and further information on items 6
through 13 contact the Lane County Building and Sanitation Division.
() Will be held in this office until you can resolve the problems indicated.
() Is being returned.
() Your building permit appl ication fee is being returned under separate cover.
LANE COUNTY PLANNING DEPARTMENT
135 Sixth Aven~e East, Eugene, Oregon 97401
PHONE: 342-1311 EXT. 231
LANE COUNTY BUILDING & SANITATION DIVISION
135 Sixth Avenue East, Eugene, Oregon 97401
PHONE: 342-1311 EXT. 411
C55-28
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, ,
SITE INSPECTION
ApPROVED / / DISAPPROVED / / DATE
,I NSPECTOR
REMARKS
FOUNDATION INSPECTION
/'
ApPROVED / 1Y / ,,0 I SAPPROVED /
/ DATE;J.- )(,-11.( I NSPEC;OP
REMARKS
FRAMING INSPECTION
ApPROVED /~' 01 SAPPROVED / / DATE~'
REM""~iJ~ r
3 ~1/"f.""Eno' (!
LATH OR SHEETR~5PECTION
ApPROVED / ~/ DISAPPROVED /
DATE
3-/ L/~1L(INSPECTOR ~
/
REMARKS
FINAL INSPECTION
, /
ApPROVED /L../f DIS
/ OHE t, 2.f · 71/ I ""no, &
'f .
-J"'Jf'/} 1/
REMA~KS/Jt{)
/)(.;yf ~ Q'-/6::' /fJ{'
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CERTIFICATE OF OCCUPANCY
READY TO ISSUE / / NOT READY TO ISSUE / / DATE
INSPECTOR
REMARKS
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..FhA. FG-i?M NO. 2573 u.s. [ RTMENT OF HOUSING AND URBAN DEVELOP/'
1.R'l.~t:10?7
- '),j 7' Ii. "J(7 F.EDERAt HOUSING ADMINISTRATION
:BILLED -0: -, --mO. ,,:L-I)(.J_ ?~=5 HEALTH AUTHORITY APPROVAL
bATEt, -6 -7J1 I ..., -"'7/INDIVIDUAL WATER SUPPL YAND SEWAGE DISPOSAL SYSTEM
PAIn <r ",_ ~ /h .J:)
. PART I -TO BE COMPLETED BY FHA
J?- ~ -:J...d
First National Bank of Oreg~n, Real Estate LOan Division
i 11,
Mortga&ee - r;ume. Address and Zip Code (',' \!::;: Co --, Mortgagor or Sponsor:
I 'I? ;--... . fYII I .
First National Bank of 0regod, ~v. ~'-;(1-11 "Fust National Bank of Oregon, Real Estate Ln. D
Real Estate Loan DiVis~'lon I'~'/-""":' folle$7~,ddress:
P.O. Box 1786 4 MillY] ~ ~ . 278 Canterbury, Springfield, Oregon 97477
Eugene, Oregon 97 0 1: 79 "',-.... I
,71 S'ubdiviSIOn:
......,.....DN! 1--....
............/'EM.,., ",-C'ANTERBURY VILLAGE FIRST ADDITION
BASEMENT ........,., PI ?~j New Installation
D Yes ~No
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Form Approved
Budget Bureau No. 63-R0296
insuring Office
FHA Case No.
L
Lot No.
d/..f, :2.
9
"T'~~W!RF:R
r rVTNG UNT'!'''' Rl<OR()().MS..J BATHS
Can Attic or other Area be made into 'additional
bedrooms? (If yes, how many?)
1
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1 3i4
DYes @ No
SYSTEM DESIGNED FOR
WATER SUPPLY BY:
~ Public System
SEWAGE DISPOSAL BY:
o Public System
o Community System.
o Individual
No. of
Bedrooms
Garbage Disposal
o Communi ty System
~ Individual
3
DYes
~ No.
PART II. - TO BE COMPLETED BY HEALTH DEPARTMENT
HEALTH DE PARTMENT INS PECTOR'S SKETCH
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t:'::'={ ::,$1:::: :::: =*= = == = =1- _1=1= = = = == _ _1=f'~I= = = = = =:;1= _~ ._11'= = = = = = 1=,= = = = = i'
1_______ ____ ____ L_________L_LU__ I --------
- - - t = = = = = - - 1- = = = = = = = I: = = = = =: =1= = = =1+= r-t= =-F = = :
::::::~~~~ ===:~~ ~~~ ==: ~~~~~~r~ ~ -: :_,=J,=,=::~ ~=
: 1- =1= = = = = = =F = = = = - 1= = = =[= = - - *-= = = = = = = = -*- = = = fit = = =[
______ __ _________ _______ __ _____L
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o rrmnt;....
::...e::J D::..:L:~1IC-0{-M"'d..l-;;ft tPat th;", individual ",.,t~",ul'l'i'y ""y""~en=
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~C1l~o::Jfc:l'-lv1J as El dgM"l~c::t;r water suoply fn;...J"Jtc ~u.L;c.~l p.Lope-Ft.:.
It is the opinion of the D State Q County 0
with proper maintenance:
4et Can be expected to function satisfactorily, and
is not likely to create. an insanitary condition
DATE ISIGNAT~R' A..A #17 fT)1 .
.c.:;I,~K,_~
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4/24/74 I RT KTRB"( iL~ _ ,M.'_H _ ~1'{'p..."iqiT\g-S.AnH.......-r An
NOTE: The health authority should complete the appropriate opnion statement above and affix date, signature and title in the
spaces provided.
Use of the above grid for Health Department inspector's sketch as well as use of the back of this form is ot the opinion of the
hea Ith authority.
Local Department of Health that this individual sewage-disposal system
o Cannot be e~pected to function satisfactorily
'TITLE
PART III.
FOR USE OF FHA OFFICE
TO THE CHIEF UNDERWRITER:
I have reviewed the foregoing and the pertinent FHA Compliance Inspection Report, and recommend that the
Individual water-supply system be considered D Acceptable [J Not Acceptable
Sewage disposal be considered 0 Acceptable 0 Not Acceptable.
DATE
SIGNA TURE
o CHI EF ARCHiTECT
o DEPUTY FOR CHI EF ARCHITECT
HEALTH AUTHORITY APPROVAL
INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM
FHA FORM NO. 2573
Rev. 10/70
-'-....,..
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REPORT OF INSPECTION-INDIVIDUAL'SEWAGEoDISPOSAL SYSTEM
PRIMARY TREATMENT consists of (jCSeptic tank. 0 Cesspool.
hptk Tank:
-,.~'._-_..
Distance from well.
Total liquid cilpacity
Inside length
Co-.pool:
Distance from: Well. feet; foundiltion, _feet; nearest lot line at 0 (ront, 0 side, 0 rear,
Inside diameter. feet. Depth. feet. Liquid' capacity, gallons. Lining material
SECONDARY TREATMENT consists of cJTile disposal field. 0 Seepage pits. Other
feet. Material
1000
Concrete
i--
I
'~allons. upacity inlet compartment
feet. Li~uid depth,
Number o( companments
gallons.
feet. Inside width
feet.
'7\t
feet.
Tile Dlapoaal fl.ld:
Distance from: Well feet; foundation, 10 feet; nearest lot line at 0 (ronf, ~ side, e9 rear,
Total length of tile lines feet. Number of lines, 3 Distance between lines
Trench width, 2 inches. Total effective absorption area in bonom of trenches 600
un~lh of each line 50-50- 60 feet. Depth, to3 of tile to finish grad..
Type of tilter material: 0 Gravel. 0 Broken stone. Other /4 Rd.
Depth of filter material beneath til,. . 8 inches. Depth o( filter material over til,. 4
10,,'
5
feet.
feet.
~quare feet.
~nches.
inches.
Seepago Pltlll
Number of pits__. . Outside diameter feet. Depth feet. Lining material
Distance from: Well, feet; building foundation, feet; nearest lot line at 0 front,~ 0 side, 0 rear.
Inapectlon made by: 0 State. 0 County. 0 Loc.al Health Authority. S'h" /k'
J .H. 00
Inspected b)
Registered Sanitarian
(nTLE)
feet.
Date of inspenion
April 8
19 74
REPORT OF INSPECTION-INDIVIDUAL WATER-SUPPLY SYSTEM
Distance to nearest public water milin, feet. Size of main inches.
Individual wells 0 arc 0 are not customaty in neighb9rhood.
Give most recent r('Cord of failure o( wells in immediate vicinity to furnish adequate supply of water
Properties in neighborhood 0 are 0 are not being developed with both individual water. supply and sewage.disposal sys~rns.
L)t size: feet wide. feet deep. Dwelling set back from front property lin.. (eet.
Individual water supply irom: 0 Drilled well 0 Driven well. 0 Dug well. 0 Bored well.
01..0_0 of woll from:
feet; tile sewer
feet; cesspool,
feet; nearest lot line at 0 front, 0 side, 0 rear
feet; septic tanl<- (eet; disposal field,
feet; other sources or possible pollution feet.
feet,
Building (oundation.
cast iron sewer
seepage pit,
Well c_tructlon:
Diameter, inches. Total depth feet. Type of casin~ Depth o( casing, (eet.
Approximate depth to pumping level o( water in well (eet. Approximate yield, gallons per minute.
Sealed watertight to depth' of feet.
Exterior space around casing sealed with: 0 Cement grout. 0 Puddled clay. 0 Ordinary backfill.
Well cover: 0 Concrete. 0 Wood. 0 Metal. Openings in well cover watertight: 0 Yes. 0 No.
Pump: 0 Shallow well. 0 Deep well. Length of drop pipt' feet. Pump capacity gallons per minute.
L>eated in: 0 Basement. 0 Pumproom off basement. 0 Pumphouse above ground. 0 Pump pit.
Pumproom properly drained: 0 Yes. 0 No. Pump mounting watertight: 0 Yes. 0 No.
Type of storage: 0 Pressure. 0 Gravity. Capacity gallons.
Has bacteriological examination of water been made? 0 Yes. 0 No. If answer 'is "yes," give date 19_
Quality o( water 0 is 0 is not satisfactory for human consumption,
Installation 0 does 0 does not comply with approved exhibits, i( any.
Inspection made by: 0 State. 0 County. 0 Local Health Authority.
Inspected by
~eet;
Date of inspection
19_
(TITLE)
GP C 900.682
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SLAB FLOOR
PLUMBING GROUNDWORK
ApPROVED I
I DISAPPROVED /
REMARKS
GAS PIPING GROUNDWORK
ApPROVED I
/ DATE
I DISAPPROVED L___I DATE
REMARKS
ROUGH PLUMBING
ApPROVED /~/ 'DISAPPROVED /
REMARKS
ROUGH 'GAS PIPING
ApPROVED I
1_ DISAPPROVED /
REMARKS
FINAL PLUMBING
ApPROVED /.it' I DISAPPROVED /
,
REMARKS
"
FINAL GAS PIPING
ApPROVED /
/ DISAPPROVED I
REMARKS
CERTIFICATE OF OCCUPANCY
READY TO ,I SSUE I
I DATE '} -//-;;'1
,
I DATE
. ,
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INSPECTOR
INSPECTOR
INsm;o~
I NSPEqOR
. i'
I DATES""'~V)t..j'INSPECTO~P.. '.
- VtTC
. . .
I DATE
/ NOT READY'TO ISSUE /
REMARKS
/ DATE
._i
INSPECTOR
INSPECTOR
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P~#~EDSUBSURFACE'SEWAGE, DJSPOSAL~:~TEM
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(Exhibit NCf.' 1), ,. Permit No. 93-#
~~;Z.4~"&lprlrJ~7ilu~C/~cZ4~.J.' ,
, No... LiYing,.. units.' Beclrooms:.. .Baths- Basemen~,.. / Water,StiPI>.l.Y. ,/. . , " . .', ',: (/. '..
" . . I:' ,~:;",., /" e:3:. ,,' " d.. Yes~" 'NO..x ", COnunun.ity .,',:~,.'Publi~.." Other-List_
".
,Septic Tank:
Ft. from well '
Inside Dimensions:
Length width
Steel'
, Ft. .
.. . X'"
,Concrete.' ,
No~ Compartments
.Diameter
Depth'
'Gal.. Capacity /tCJ ~c::?
Tile DispoSal Field: ','
Distribution Box: Yes~ No.."...,
,,,,,.--'i . ,
Other Distribution -'Type
L _ ,. "."._"
L-C/~ ~),6?"
. I, ' // Feet from
MailinCJ '. YtJ dt/ ~//;//'?f :J~;r;' " Well ' 'Foundation /-7)'
Addr'ess . J/A AA~ 2:';'/'A /J..4, /J/JV'.' ..,', . " Lot' Line. ' ./ =)' /?""
rnq~~ lHi~~(ift:-'~~r.ff.~~lJi:~fe:~en~i: Im1#:;t~ al;;Pi~
Plot Plan dSeelnstruction.s', : 1'". . ' ,
l_.-:-~:=i ~~i"",.,.~". L=,:.". =~I=_,...,,~~_I 'T____=___:_::.~='
L "'..'~,....-,____ ,""'" - ..__ _____ ,--------o--',..--,..-..-'..'-....,-..--.,--.,--..~-.......-
Applicant
Name
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t,'-'L_',.j ..'1--'-- '.C--~--~~ ~~ ..----,,~~.
\, ~:.~,."!,::',:'.~.-,',-'11I',,..n,..,..,',','-,,','~:,:,'..-,., __,.n... '~n ..... ,..=....,' -~-..... -~, ,.. I.... ., ~,-' '1;. .~.~.. ~,(:...~. ~.~.'.~.. I~l.'-"_/... ...~.~:c.:: :~::-:::::~ -. ,
: _ .... .. -ro.'" _, 'p--'--r rl _ ~.,_.~_, ~".",...,__. ......._....~ _:.~_~_,,_ ....____,_._l__......,,;. ....___ ~_..__.,-,__:
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~~ ~ . ~...... "1, -. :-1,!~I-" -- ~--: = -~, -;-- C:~~:::2nZ-: it: -:l,.~::1:49{t,:~.... :ii~~::!..,.
.. f! I --.- -~~T-l----- jLU_L_~~.:...j~ ___~K__~_:
Date~/ /}'I) ~;7) ..m. ----.;i~~~~~-~~~t':-"~~
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. For ~aria'n Use Only: . ' . . '\ '
~~~;oved: System Installation Conforms to DEQ Rules: for Subsurface Sewage Disposal
o Disapproved: Does not Conform to DEQ Rules for Subsurface Sewage Disposal
.. . Data<~Z(IY
(t F:fr 0 (A ---L<
~itari~n'8'si~~~ure
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Remarks:
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Interim Form #2
State of Oregon
Department of Environmental Quality
LANE COUNTY r n1NG PERMIT 0 R MOBILE HOME (: APPLICATION
PERMIT TYPE - BUILDING 0 . MO~ILE HOME Dose REG. # PERMIT # 9'...3 - 7t/
LZE~~) ~:AI&~RESS1"o~~ ~~~N 7~;~0997/
,~ ,MAILING ADDRESS " / / PHONE
PROPERTY ,LOCATION - INCLUDE POST OFF CE t/-tl f' ~ ~ ~ A .#?
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, /" I' ' '
PROPERTY LEGAL DESCRIPTION ~ C/ } . "#,, , /. 4./1,"" ,L-018" METES & BOUNDS DYES
LOT - BLOCK - SUBDIV. /~~ /ST...y~ 7 -~ ATTACHED 0 NO
TWP, RANGE SEe. TAX LOT ff' CODE CENSUS TRACT
/7 0=3 ~t/' , . 0CJ-~LJ/-5D
~' / DESCRIBE EXISTIN, G STRUCTURES ON PROPERTY IF ANY
APPLICANT _' , ~
NAME
LEGAL ACCESS TO PROPERTY - ROAD NAME OR #
~/~~
PROPERTY SIZE-WIDTH /'DEPTH
/6/
./
J
AND
MAILING
AREA
ADDRESS
79..30
FOR MOBILE HOME PERMIT ONLY
Number of Bedrooms
S~UILT THIS PERMIT
~- ad-~~
t7
Connect to Existing
TYPE CONSTRUCTION
\,~~
Sewage System 0 or New System Req. D
SQ. FT. /:;) '! ~EDROOMS VALUATION ,/
.1.5 0;1 t..::::-I~ L3J /'~, ();:J 't
r~ CJ ~ Q 3 --.-6 "~ / Z.
I:CfI :5 C;:)
SEWAGE DISPOSAL
PUBLIC 0
BLDG.
WASTE DIS.
PLUMBING
PLAN REVIEW
PARK TRLR.
SEPTIC .TANK M
$ 14, ()I:J \
" -=/0 ,DC;
....l? q'" 0 f"'1)
PLUMBING INSTALLED BY I Af"}J1 .
OTHER 0 OWNER 0 OTHE~ NAME LttJ~-:t:/tnlf#[9;
WATER SUPPLY PLANS FURNISHED \. FACIlITY/PERMIT -, 7
FEES
PUBLIC 0 OTHER YE_S)2r NO 0 YES cY' . NO 0
PL.,UMBING FEES @!.3 ~NAT~F A?9CANJ..--~' d ~ , /DATE .
,/CJFIXTURES 0t)..Z;O 7U-i:{.: ~~~//2-V//</
CASH 0 SEW~ .FEE RECEIVED BY I DAtE / '
CHECK ~NECTlON FEE d ~ cJ t!J X ~ 1/:2 <./ / ,(/
PERMIT #. c/ /Iy/ OJ - /
PUBLIC WATER "'1 /l 0
CONNECTION FEE d ,,(/ - q ( ':J -7 ,d
COUNTY BUILDING & SANITATION SPECIFICATIONS /
DRAIN FIELD REQUIRED ,llZD 0
lIN. FT. I UO TRENCH ~IDTH FT, IJ..... OR SQUARE FEET
f'''-f:[ ,:, ('eo! Cl,;- peA pi" -f 'F Jq /l .
TOTAL
/3 $1 00
MIN, SEPTIC TANK CAPACITY
WITH DIST. BOX: GAl. q DO
fY Q elL\. v-J ct"V -\ ~:J s4e.......
'--""'"
TYPE OF STRUCTURE
....-
-!fIV
ZONE
REAR YARD
PUBLIC UTlL. EASEMENT
OCCUPANCY, ,d
. laY^!
BLDG. SETBACKS - FT. FROM CTR. OF ROAD RIGHT OF WAY
FRONT . ~ CJ f SIDE INT. .s- t SIDE EXT:-
~~~f\ \\ a I late PLANNING
,~ 'J../7 '1;<4 ~
l
USE CLASSIFICATION
Date
REAR '7 I
BLDG., INSP.
L*
,U~
f
, /J - /:;/"p Dale
~t~11' (.ff!;{. $ ~ c.? '7 L'
/ - tf). J:"- 7 'f
Directions to Find Property:
COPY 1 - OFFICE
COpy 2 - JOURNAL
COPY 3 - AUDIT
Form # C55-12