HomeMy WebLinkAboutPermit Plumbing 1996-6-19
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...-\1._ CuUi" I' . SEWAGE DISPOSAL SYSTEM "AS BUILT" PLAN
.. ,!VIi~ONMENTAL HE. 'M" ,
pursuant to UlC fequiremcnts witt,;" OAR 454.665. OAR 34().7t-170 and OAR 340-71.175, the system tost.allof eOdf<< the pennitt_must notify the department ofL" .._.......__31 Ouatrty
{or
its authorized Agent)Yotlon!he construction, atterationorrepeM of a system 10r which a pennit was issued is .-r . ,.: (except for the badlfdling or c:ovcri'lg of the In;$tallaliol'l).
'The
0cp3r1.t'nent( orAgent)haSSOVOfl(7)d;Jys\Opcw1onnBfl~ofthtlcomplel8d(X)(lStruCtionanerthoolflCialnotiGedate.unlesSlhe - ...' (OfAgentI eleds to waive the
inspedioo pnd authorizes the systom to be baddillod e8f1M:n'. Rooeip( ond .......".. ,_-' of this completed fonn by the Department (or AgenllestabtisheS thl"-otflCial ootic;e<latoQ(
your
rcqvcst lor~lhepm-c:overflspedion. Pk!:t'<..~..""1hfflft ~m..l'4thnfnnn Anctrm,.mlnlIlOACnirdvE~AlHAallh 125E. 8fhA_,. EtJ()N'Ml. Or........., g7401.
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~ECTION 1: BASIC INFORMATION
Permit # 1/ ht/ - 9t.
Mapffax Lot #..1-7- fl~ -.:J:::J.. .
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To Be Comoleted Bv Installer: '
PERMIT ISSUED TO:
Name: LL ),J:tM
Property Address:
TOTAl#: Bedrooms~
1
WATER SUPPLY:' PUBLIC 1( Individual 0 Community 0 Other (Name)
ailing Address:~~~ ~_p;j- V2f
. " t'"1 -'" D..hv-<...rL -
Living Units _ Basement: Yes_ No L .
SECTION 2: Materials List (Identify and list all materials used in system):
SEPTIC TANK: ~. Concrete 0 Poly 0 Metal
Manufacturer W,\\c..."",..,"!.\. <::.___",l..,..... Total Liquid Capacity \l::I~O qat.
Distance from Dwelling \..n. ft.; Effluent Sewer ASTM # 30,4 ; Distance from welt--- ft.
DRA1NFIELD:
Total Linear Feet ~~O '; Drainfield Pipe (ASTM#) F 4nS ; Header Pipe (ASTM#) (:"'40S
Depth .Rock Beneath Drain Line [0 in.; Depth Rock Over Drain Line~Jn.
Distance of WEll from Closest Portion 9lDRAINFIElD
Mfg.rrype/Size of Rock Filter Material \J~o. ';:)~ ('~ "(-;;. 'Ki--
PUMP SYSTEM:
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.
(Complete as Applicable): Working Capacity of Chamber oat. Gallons per Cycle-----9at.
"Working Capacity" remaining after alann has activated qat .
Signature-,Qf~h ~ <tl,~
OTHER: (Materials not listed above)
Date . l~ \ \" \ o.,(~
FOR SANIT ARIAN'S USE ONLY: ..ystem Approved' 0 System Disapproved 0 Needs Correction
C, OMMENTS:p.AM'~ -co ."'f'Y'1':Il''''::UlY....., Sf ,,,,,;;(};;:;OOOAA ~A(~ ('~ /iY---'
~ ?"'O.-l71 -0(\(;:)..\ .'1 \., I:'
AA~A~ ~ 1&&1 11 &&lJ JJ JJ& Ai J1 J&& l&&lA~&& i 1J Ll11 11 11 1111&&&1
. 0 System Corrected; Date: .System Capacity 4t;;b
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Signature ~,.I,...:..._.- - . . ~Date. -.-c. r.~ '-IJ./1c.
I.NSTAllAll0N Rrf:)RO & CERl1RCAlE OF $AT1~AC COMPlETION. VIJhen signed by the County Sanitarian. this certifICate is evideOCe as per QRS
454.665 of satisfactory completion of a StJbS,UIface sewage disposal system at the above kx:ation.
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SECTION 3:
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Permit # II (,4. '110
,
AS-BUILT PLAN OF THE CONSTRUCTED SYSTEM. Show the following: North arrow, septic system
referenced to a fixed point, such as, building foundation or property corner, property lines, wells and water lines
within 200 ft., drive or walk-ways, all buildirigs, property dimensions, streams, ponds, cuts, escarpments (>50%
slopes). Include final grade shots of ends of trenches, distribution box, and septic tank outlet elevation,
~ .....******.************************.***********~*********~***.****~~********......*****.***.*******..*******.*
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VICINITY MAP
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I have pe~~ona~~y ~n6pefted the ~y~tem .
~hown he~eon and ce~t~6Y that ~t,~~
.,_co!lilil!..c:ted~l!, 6iJK, comp-~~<lcnce. wah .the
"P)I.OV~~~Oyr~'.66 -o'A'p. V-'.v' '7 /' -'-.-~'
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I certify the infonnation provided in this notice is correct,
and that the constl1,lction of this system was in accordance
with the pennit and the rules .regulating the cOnstruction of
an on-site sewage disposal system. I have tested the
septic tank for water tightness per OAR 340-73-025(3) and
found it to comply.
. '
Installer (Please Print)~e.,:,,-':(,.o \ S\~V''>
(T'rtle as shown on OEQ license) )
Telephone h 9-p, - 'l. S'II.\
Ucense No, '?'S\",'l.e"
Bonding co~nv . \\~ <l. <;~~~
Signalure~J.....vt. \~~>-._..; \
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