HomeMy WebLinkAboutPermit Septic Tank 1991-11-19
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-0 MUST BE IN BLACK INK
Permit No. 3J7(P /1 Twnshp. /'ir Range ~ Sectig", e,{2. 2-
Standard System ~Alternative System 0 ~SpeCif'i. Type) #;l) tL.DI.<t.,..,.f tf..
Job Location (Street Address)-Q7../ 0 - ~ <:'-/-. ~fr'...", P.~ {J
Supdivision/Partition # Parcel Y Lot
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form c55-,..tl
Tax Lot_/70 cJ.
Block
DETAIL SYSTEM PLOf PLAN AS CONSTRUCTED
If It. / I 11.. S I j " -10
::[1.J!1/)'f pvr~4't .::US~tC~ . cae =
5'1 sf.ott-t .s 1/ot<-11 ;11'"(1)< ,1 ttld.. ~
c~Y'f; ~ ft.sf ~/. tf.,;", ~-v fI" ~
0.~[,M"(C/e' 1 p 'f-<t/I cin-<<. - .- _. !:1.;s't,:V, N
fl'4>1ce w/~ pra~is~;;'.:~ d/ .
cuft!. ''6'11 -r:;>'l/i S{~ 71
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USE BLAFK INK ONLY " "
FOR INSTALLER'S USE: Trench Depth :!. </' Gra)lel Depth Below Tile ~
Tank Capacity /000.,r>t Manufacturer. C",.._....", ""=>.......Q'. .
Measured Distance from Well to Tank <"<:. r . From Drainfield 70 ( Total Length of Lines =<: o~
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.
Signaturp _ Datp
FOR SANITARIAN'S,US. ~ ONLY: -/.~, s.r~eZ::=1t..d~ ~SJt!:,m Disa~ 0 Needs Cmrection
COM,MENTS: -, . //hV' ~A'...< _.. .1'"".,........ ~~
--A~'t!~~;;; .-.....~ j.i+-r-.. . "y- f~;::ep -tf.,..M"-~
P' L~System.Aorrected Datp
System Capacity y~-tJ gal./day Signalure,... ~~. _~ Date_11-r"--c:..fl
INSTALLATION RECORD & CERTIFICATE OF SATISFACTORY COMPLETION When Sig"~y 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 01 this form to: Lane County Environmental Health Services, located in the basement of the
Public Service Building, 125 E. 8th Avenue, Eugene, OR 97401.