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Home My WebLink AboutPermit Miscellaneous 1980-7-28 LANE , . COUNTY BUILDING . PERMIT ~ne county - POST' THIS PERMIT ON MAIN BUILDING AT 5ITE c CONSTRUCTION PERMIT # LC 1960-80 t9 JOB ADDRESS: 620 Dorris Street, Springfield, Oregon TRS, ;L~ 18-03-02.2, 1800 J SUBDIVISION: Amended Plat of Willamette Heights, lot 13, block 12 CONSTRUCTION APPROVED BY THIS PERMIT: Repair existing sewage disposal system CONDITIONS OF APPROVAL: Pump tank. Replace with new if less than 500 gallon capacity or in bad condition. Properly abandoned old tank. Water test existing line. If line is not failed add enough new line to equal a total of 150 feet. If existing line is failed, add 150 of new line. Install only when the ground is dry. Hand rake sidewalls of trenches to prevent smearing and , scal ing. Install a serial distribution system. NOTE: This repair would / not be adequate to serve more than a single occupant. SDS installation specifications: 1,000 gallon tank; 150 feet total feet of drainfield; maximum depth of trenches; 24 inches. Keep dratnfields at least 10 feet from all foundations and property lines and 100 feet from all water sources. Keep sepfic tank at least 5 feet from building foundation, 10 feet from all property lines, 50 feet from all water sources, and 10 feet from edge of right-of-way. . PERMITTEE: Steven Shaw DATE ISSUED: July 28, 1980 BY: Kathy Weiderhold/Carol Dyal DIRECTIONS TO SITE: Springfield - cross bridge (twin) onto Second Street, follow approximately two miles to end, left onto gravel road. One-fourth mil e - red house on left. WP 28305-5E-2 * * * * *.* * * * * * * * * * * * * * * * SETBACKS AND OTHER CONDITIONS OF APPROVAL MUST BE STRICTLY OBSERVED. VIOLATION CAN RESULT IN REVOCATION OF THIS PERMIT, CITATION UNDER PROVISIONS OF LANE COUNTY'S INFRACTION ORDINANCE, AND/OR OTHER REMEDIES ALLOWED BY LAW. WHEN READY FOR INSPECTION (see attached) call 687-4065. Have the following information ready: Permit number, job address, type of inspection, when it will be ready, your name and phone number, and any special directions to site. OTHER QUESTIONS? Call 687-4394. Ef\JVIHONMENTAL MANAGEMENT DEPARTMENT "25 E.ASf 8TH AVENUE I EUGENE. OREGON 97401 TRS, TL.~-(')~-()22 <i"13CX) Job Location (Address) <060 ~..) ~((. Permit {J \<OJ/aD-X'D For l1)fJ!a!ll!- ~, Permit {J For . P I at P I a n Permit {J For i . ,:'" Permit {J For Permit {J For ,'l-. Permit (J For . , SUbdivisionGjIJJ(\"""."iiD>~ t..:;X:! ofl-~ ~t.<<'- _J:\P~"'" Lot I~ Block. Ie L U ~ .w s~ ~. Q:I '" 'f" . j.~7 /) \~:. ~ df> I\~( . ~A.~)hJ J alfflJ rt""'" ~ "l~v- , ~w . ~~ ~\)I- $:Q.," ~: \~~ > i k. t.rjJ,^~~ ';t '( ." ~,\\Y' Q ..~\ 8 ~ll ~\e; ". "{\o S\~\)J ""_ _ J.- 'oJIP1dll'- i'''l... ~ - _-"& o~ ~ . ~ J ~\ -,2-- ~ \ . to ~ Q 01 ~-.g + ~~.; ~~q -\$ ~ . ~1:L --/ ~o y-- \ "- ~ '0 -.. , ..t' ~ :3 ~ ~ e 'i;:' - N Vicinity Map C74-150 , ~ ' / , ~eRIcJ51. . . lane county Water Pollution Control Division Environmental Manaqement Department 125 East 8th Avenue Eugene, Dreqon 974Dl LDCATION: Twp. IS Ranqp 02 Section (D, Tax Lot # \ro:) (Complete the following, if applicable) Subdivision Name:III/ l/rlrtY1()tt ~ J Lot # 1.3 Block # (7) r~ - I have no information that the existing subsurface sewage disposal system located on this property has ever failed by discharqing sewage upon the ground surface or into public waters, by clogging or backing up, or in any other manner. ~I have information that the existing subsurface sewage disposal sys- tem located on this property has failed in the past by discharging sewage upon the ground surface or into public waters, by clogging or backing up, or in some other manner, and that: D The system has not been repaired. D O The system has been repaired and has operated since the repair without other failures. Date(s) repaired , continuously 11 I have had personal knowledge of the performance of the eA~ting subsurface sewage disposal system located on this property for ~"">+- years and months. The existing sewage disposal system consists of: a) Septi c tank has ~ _ ga 11 on capacity. b) Number of dra i n 1 i nes--J. . c) Length of drainl ines , , d) Distribution box? Yes No The existing septic system was installed under Lane County Building Permit # This system last served a dwelling having ~ bedrooms (include all rooms which could be used as a bedroom, though actually used for-other purposes such as for a den or a sewing room) OR, if for commercial use, this system last served an establishment having employees, and gallons/ day sewage flow. This system was last used on(llll1J:t Ol'n+ I l;<:' .(Date). In case of an addition, the new portion will be fee~way from the existing drainfield. ~ ......... /J./ APPLICANT:..,...,.d"~~~~_..--J .. :' PROPERT1..QWNER: /~es' No DATE: . A 1 i l..Jx- . ." . ~ U .....= -' C74-156 lo...S'7 . (Date), WATER POLLUTION CONTROL OIVISION I 125 EAST 8TH AVENUE I PU8L1C SERVICE 8UILDING ENVIRONMENTAL MANAGEMENT DEPARTMENT I EUGENE. OREGON 97401 I 15031687.4061 II"" )<10 . . OEPARTnEiH OF EflVIRONi1EilTAL 11ANAGENEHT PSB, 125 EAST 8TH AVENUE O.:,~l.ttui ~l1.to~ U1ll~n~~~lil~1 Job Address 0 (//,) ';tjt'''~RI r s;T' a....~y ~/l/or/L':L'/) Township, Rang;:-S;ction, Tax Lot' /?'-/J_7-~/} '_~/\ #1(;11/) Subdiv""u," ~.t,~,.;...:--- .'.::-1.' Lot \? Block 10 Application for iV ~LJA/# . )j?~/~ -r/l/l//t' ,I. /)~,,(hA/ Structures now on the p;operty /-//J //.!f" .:: r.- MA'" /- .'i#~A -"oUA<'?.e.&S~ Proposed use of property: ~Residential CI Corrrnercial I~I Industrial C/ Publ ic Affidavit: I. .:5"'7').-;;e::;9A;./ p. <:::',#.A:lAI , hereby certify that this information is true and accurate. (please print) . If this application ;s for an agricultural building it will be used for purposes allowed by the State Building Code and Lane County Code Chapter 10 (zoning) and for no other purpose. I have the following legal interest in the property: owner of record; contract purchaser;# lessee; holder of an exclusive option to purchase. ~.dulY authorized/t.9'a..s..t for"che owner..... ~~s..knowledgeable of thlS application. r::. r-1L/ Signature/Address ---f~,/-Y/" P~~J..) ~~ AyA(7/'?,,! r?,~ Gr\ (ZiD19/),yIJ~ 11l"ePh9ne ~ - ~/ rF-- or , Date I) - / F." -li=rl When pennit is ready notify: . ~- Appl icant ~ /}f"Owner C/ Contra~f- - ,- Owner C j ,,;:, l/ (" /,,) /<? I r::? A.I -r- C:J /0) Ii'ln/'JL// r ("/ (z i ~) 9?-?-1J /) Phone I) ~ L',-.- / S- .P , J Contractor Contractor's OSR# L !!~~)~70 Assigned Numbers (zio1 Plumbing by = If Commercial: # of stories Residential: # of bedrooms .Q SI test holes ready DD NOT WRITE HELOW THIS LINE # of employees # of units / 50S: ~xisting, BP # I~I Proposed, SI # Sq. Ft. or Unit # of Sites Cost Valuation ..{)Ql Q Y"b~, n.17J(~c:::3LL->, . U - \ Fee Fee Code Description t~(j I rt ~ ~( I . ()f)( [~L/Y)'"'X" '\" I ="")1.I'0dIJJYY\ - ( ) iT '-/ ~ $ $ $ $ Total Valuation: $ $ Plumbing fixtures at $ each $ CI Cash Sewer/water conn. at $ each $ CI Check # Subtotal $ Received bv 4% State surcharge $ Water Supply ( 1 )0 J ~Wsting / Plans check fee $ Proposed Change of Occupancy $ Year Installed TOTAL $ e5A-. PERMIT PROCESSING' Zone RA- 1-, fr~nt Pa rt. # Parcel # Parcel size~i"Jl()-, 1-, side COnlllentsl'5J Y'\:tO/lY-li.. 'J (.--J~CJ no'+- ?JL 1M if) -~""i), Xl V\d1J1~ I ,"Yy To be typed oOennit L )).,I.crf)tJ hU !o /l) eN. () _'" ~- / I " ~ / By t'Dh. Date -;(/I'X/;><I)L/ WATER POLLUTION CONTROL - ( / ,- Installation specifications: e,,(l~. tank; 1q}1,,,,, I ft. of drainfield; max. depth of trenches: "I - ~ 1,..., I . . To be typed on permit :i 50 Minimum setbacks: ; into ; rear ,~/ CP&I CI WPC I~I Plannin I~I Pub}; Works . {} levation CI n/a I I Address I~I Fac; 1; t)' Perm; t Environmental Health , ./ 40 ~ ed.)4 nl~ 6-6-. ytcrLL~OYI a SRflJ5) ci0ktlorA5llM-/~. MDJe:\.Jfuo ~ l1nAJ.dMik& -h> -SetWt ~ %aVt fA ~& DC~ ..4 . . ""'II INSPECTION RECORD 1. Site Inspection 2. Foundation Inspection 3. Framing Inspection 4. Lath or Sheetrock Inspection 5. Final Inspection 6. Slab Floor, Plumbing Groundwork 7. Gas Piping Groundwork 8. Rough Plumbing 9. Rough Gas Piping 10. Final Plumbing 11. Final Gas Piping Remarks: 12. Certificate of Occupancy: ready to issue; not ready; - - ~ ~0 -f' f,/(i1~~?f:>(I2J PW()~ 0 {;p~ ~(f) T--1 "-.JI--J. . C-~ ~/ Approved Disapproved Date r o n l> -i ~ o :z Inspector '" m ;0 :;:: ~ -i "" date; inspector. . ~tO ~,,~ @\ ~\~'l~~ ! l-"O ~ C\ .rn. ~ ~ t/I"O V ~" ~f\~' ~ ~-()" -~-(~I @ L -# ~~~1~~ ~ (j) . YV\j". ('-?~ LANE COUNTY DEPT ENV MGT F(ECEII"T ~'i960B0 DATE 07iB., APPLICANT SHAW, STEVE ADDR 620 DORRIS ST. SPRINGFIELD TL; 1803022001B00 SUBDIV WILLAMETTE HEIGHTS LOT 13 BLK 12 NEW BLDG TYPE USE R NO BDRMS 02 NO UNITS 001 NO STORIES NO BLDGS 001~ CODE AI"I"L NO ACTION DESCRIPTION SQ FT UNIT COST VALUATION FEE DAYS BP BP BP BP BP BP 1 -;~ 3 . 5~ . ,~ 10 -. ..!!. 14~ 16 -. " -\ I ..~ " -. l4 .!!.. 28 -. .. ''- i -'!. PL MECH SLm PCI( SDS 34 -. " 1!. .. --. CATG: SEQU: TAKEN " -, I ..!'.. .. -. 48 2'.. ..!!. . S4 T! 1!. sa -. " ..!!.. " -. NO. FIXTURES: . NO. CONNECTORS: MECHANICAL FEE ST A TE SLmCHAf!GE PLAN CHECI< FEE SYSTEM LC 1960B0 SDSR FAILING APP 1 BY CAD RA FP SDS SI F'CI< 2 EST. COMPLETION DATE 072380 . 5.00 EACH -- 4% ~50% OTH ISS ~, TOTAL. FEElHf ~ ~ ~\ ,. I . . . . . . . 25.00 . . 2:>.00 '( li ~ .- .. . " I ,.. 10 <.., [- . '~ - ,." 3 . . . 4541 DICTATING INSTRUCTIONS CONSTRUCTION PERMIT # 1 JOB ADDRESS: 2 TRS, TL: 3 SUBDIVISION: 4 CONSTRUCTION APPROVED BY THIS PERMIT: 5 CONDITIONS OF APPROVAL: 6 PERr~ITTEE: 7 DATE ISSUED: 8 BY: 9 WP 28305-5E-2 ************************************************************************************* This is , 24-08-25, Program 011, extension , dictating a building permit (or buildinq permitsJ on l~ord Processing Form #28305-5E-2, with 4 copies. These are final copies to be single-spaced. I will need them by morning, afternoon. I will come and pick up. Please call when ready. Just leave message. Note: Please type all numbers in numerical, unless otherwise noted. Variable 1 . Capital / _ Capital C Space Variable 2 5tr Va ri ab 1 e 3 !.f hyphen 03 hypen 0..;<. per i od _ ,.;;( Variable 4 (If none, just say NjA) If so, give sub name, Lot, Block.;llt 5 Go to not~ or application. 6 Go to notes or application. 7 Appl i ca~ s Name 51t- 8 (Day after dictation date) ,!l.r-'6 Variable 9 Plan CheckerlSanitarianjPennit Processing Clerk (You must IS?, "slash" names, and not. all names are necessary, see notes). 1?~1 C () )(Directions to site, colon - ...l!l.d of permi t. ~ New permit. Start over. )9 ~ 0 hypen 80 (All caps TMH or MH) PQriQB comma space /Boo. Variable Variable Variable Variable between NOTES: Variable 5: Variable 6: Text: WPC: (Repeat below if applicable, plus text, if applicable). Subsurface sewage disposiiJupstem installation specifications colon 1.000 gallon tank semi-colon ~( ~e~ of drainfield semi-colon maximum depth of trenches semi-colon2-{' period. Keep drainfield at least 10' from all foundations and . . property lines comma and 100' from all water sources period. Keep septic tank at least 5' from building foundation comma 10' from all property lines comma 50' from all water sources comma and 10' from edge of right-of-way period. Paragraph (written comments) Paragraph Planning: Sff- - 5rtJ~ U Minimum structural setbacks colon from centerline of semi-colon side interior property lines comma property line comma semi-colon or period (side exterior of road comma ) period. road comma front comma semi-colon rear comma from centerline Paragraph (written comments) Paragraph Directions to site colon End of permit. NOTES AND SUGGESTIONS: Variable 2: Variable 5: Variable 6: Variable 7: Variable g: Suggestions: If on a new SFD please look at addressing's copy of new address. If on a septic installation only, there usually is not an address, just a road name. Spell out unusual road names. Spell out SDS (subsurface sewage disposal system) don't abbreviate. Sometimes there is not room on the application for the construction and the septic so the clerks write it down by the fees so be sure to look to see if the permit is for septic also. Always hypen and put the square footage of the structure(s). Prepare this before dictation. Sometimes it instructions (not always the regular format) (not always in order). Always say paragraph Spell unusual names. These names will differ due to who is involved. One permit may be all 3 names and one permit may be just 2 names.. For septic only put the sanitarian slash clerk, building only put plan checker slash clerk. Spell names if unusual (McGuckin, Cruickshank, Weiderhold, etc.) (a) Speak clearly and say s as in Sam and f as in Frank for those type of letters that sound like other letters. (b) Always say comma or period if there is one; also parenthesis. (c) If you make an error please see Dictation Instructions sheet (d) BE PREPARED. Have all applicable notes ready. You do not have to write down everything you are going to say, on sheet just write "see app". Just be sure you have the papers in order to dictate from. varies, and the between such as the septic setback requirements' different texts. . . DEPART/lENT OF ENVIRONI1ENTAL t1ANAGEMENT ~ ~ ~ffi4~~ ~N .~~6~UE . . ~"':: /Jf~p 2 -.tflitA'''.c-..w ;$=:J:.:~:!;;!l!l%r~~~~~,*gi!: ~ <~ - ~ - . . Ll&t. l ~l!Jalilii I Z, Application for LJ//n? c ~ P7>r 7W.n.61:-~ /)R',,!u/ . Structures now on the property /7""-~ y/ - r.; AL7A6E-.~;} -"ouA.>?~~.f~ ;~.}J$iTi!"][Rflllfl!pi!!l@ii g.~I!!~~I\i!~lj;l} O:SB.trtjiiU 0 iiU@~}ift'~1tUt 1_::/ilIDlljil~!l Affidavit: I. S7 ~A~'~liitl~~.A Z. / , hereby certify that this information is true and accurate. If this application is for an agricultural building it will be used for purposes allowed by the State Building Code and Lane County Code Chapter 10 (zoning) and for no other yurpose. I have the following legal interest in the property: owner of record; contract p~rChas r;# lessee; holder of an eXC.lusiVe option to purchase; _~ duly author;ze~ ~.t.. f,vo,/-r t.he owner, w "15 knowledgeable of this application. C" /1L? Signature/Addres,<-J../"/..hf'__ P.. ~~) 1'['ri4l ~-q4,1' l'/.:. ~ cr" (ZiDl9/}~/}/) 1'elePhon;~e:;-<rI.r'y or - . - Oat., ? - ,I fi" -~ - When pennit is ready notify: 181 Appl icant~ QrOwner CI Contra~ - Owner r::l A~Y (' U) ;'Pt,a#-r C:J./Il l),.,nL//1 r/ (zip)9?~1}1) Phone ?~/.S-/S-p Contractor (zip) Phone Contractor's OSR# Plumbing by .~ ~ ~:S~~::~:~~l :1,i'II~IIIi': ~ 51 test holes ready DO NOT WRITE BELOW THtS LINE # of employees ~ji~tlqn!~1ft I$ij~!il - Existing, BP # I~I Proposed. SI # ill~I~~~llIil ~111 Valuation _L)fU f "nO' ;r\I~('U) Fee II .iljiiliiiiptilliF . ~ 'h t ,()1X. (:='It lfY)'X '- .~/YY\ ( J - I' . - ......., g 1.lli"c Received bv Total Valuation: $ 11I~lllllllli :: : Subtota 1 each each $ $ $ $ $ $ $ $ $ $ $ $e-sm Water Supply ( Proposed Year Installed ). ;0 H /'" E";;sting ---1,L 4% State surcharge Plans check fee Change of Occupancy TOTAL = Zone RA- Part. # It. front It. side corrunentsQJ ~~ J 0~ ncrJ- ?JUM +r-) ~,5\ J nd1~ 1 \~ To be typed "f)ermi ( kP-t (w)lJh J u~ .If _, ~,9 () .. '..:y 1- - () r- . IJ By -LtUlJI1L Date -LLlD 1Ci.) CP&I Type Group ire Zone Use Classification f I - I To be typed on permit PERMIT PROCESSING Parcel # Pa ree 1 sizeMrll(L Minimum setbacks: ; into ; rear By For plans information call $O~t-~e . CI SIFO Plans to: /~I CP&I CI WPC CI Planning CI Public Works I~I Elevation CI n/a el Address (:1 Facility Permit I-I Environmental Health 6n.Jo ~ ill. )4 ~ tkL c<fuX.. OY\ ~. " Date Phone - ( O"O~ r: Hold Slip to pec Date Camp 1 e ted CP&I WPC Date Required C74-171 . . INSPECTION RECORD Approved Disapproved 1. Site Inspection 2. Foundation Inspection 3. Framing Inspection 4. Lath or Sheetrock Inspection 5. Final Inspection 6. Slab Floor, Pl umbing Groundwork 7. Gas Piping Groundwork 8. Rough Plumbing 9. Rough Gas Piping 10. Final Plumbing 11. Final Gas Piping . Remarks: 12. Certificate of Occupancy: date; _ ready to issue; _ not ready; Date . . Inspector inspector. ~ c- o ("') :>> --l ~ o z .", fT1 '" 3: ~ --l "" -- ~. . Job Location (Address) (060 ~({' ~((. Permit 0 \0(,,0 -9,D For I J) 1/)/.1 1. ~\ permi;-' For Permit 0 For --. 1)..0 'Permit ,. For Permit 0 For \,r- .' Permit" For , ' ~.l)" . \0/5)- YvJ~ ~\'\'i.~ rL~jJJ.N- r Sil1 '?k V ~ ' . Q.I / '\ \ l~'.. 'I QJ; ,\l\( . 'xii~.#1 ~(/tj) "'(~J \ \:j\'"'- "r- ~"" . ;.,,\r \'i'~ ~ . ~~ - ~ . t}\fJ,W'llv6 ): S\I\JJ ~ '(\O J~ OCl.: TRS: TL.~-(')()-02 2 '*'1&::0 Plot Plan SubdivisionJ.:"~/J j fa Block Lot , tt)(~ <!l''1I. / oJ(}:. I..-~ QJ I ~ ):1 Jr ~( '\j~8 II, ~\~ ~ I, 'ofJ'\d';- - --1-- ~ -l'~_ ", ~ --- ----1 \ --'- \ "- <;:) o ~ . -~ ~ ~ ;S <:). ~ -e .;;;:- toa1 ~ Q ~ \D_.g Y 1~~ ~~d ~ .?E ... 1" -f . ~o :r---' " / , -~0<JcJ5,. . ~ N Vicinity Map ....,J._1c;,n - . 7%~d)5'L y / dM:r:J 'tal iUUL 4.t aJtz" 0W4.t ... . '".:;. .' . . ~._- ! 4 f . . , .. POST THIS PER/aT ON ~.AIN BUILDINC AT SITE CONSTRUCTION PERrm Ii LC 1960-80 JOB ADDRESS: 620 Dorris Street, S~ringfie1d, Oregon TRS, TL: 18-03-02.2, 1800 SUBDIVISION: Amended 1at of Wi11amette Heights, lot 13, block 12 P CONSTRUCTION APPROVED BY THIS PEP~IT: Repair existing sewage disposal system CONDITIONS OF APPROVAL: Pump tank. Replace with new if less than 500 gallon capacity or in bad condition. Properly abandoned old tank. Water test existing line. If line is not failed add enough new line to equal a total of 150 feet. If existing line is failed, add 150 of new line. Install only when the ground is dry. Hand rake sidewalls of trenches to prevent smearing and scaling. Install a serial distribution system. NOTE: This repair would not be adequate to serve more than a single occupant. SDS installation specifications: 1,000 gallon tank; 150 feet total feet of drainfie1d; maximum depth of trenches; 24 inches. Keep drainfie1ds at least 10 feet from all foundations and property lines and 100 feet from all water sources. Keep septic tank at least 5 feet from building foundation, 10 feet from all property lines, 50 feet from all water sources, and 10 feet from edge of right-of-way. PERlHTTEE: Steven Shaw DATE ISSUED: July 28, 1980 BY: Kathy Weiderhold/Caro1 Dya1 DIRECTIOt5 TO SITE: Springfield - cross bridge (twin) onto Second Street, follow approximately two miles to end, left onto gravel road. One-fourth mil e - red house on 1 eft. WP 28305-5E-2 - T'RS,n j g - c '3 -07-1- "" /ioo VICINITY MAP ~ ;.-- ~- 8l~t -:It \r -" ,ll( .~ (\ @~V> 1)OY'/'"loS -'::>w ~~ \J ~ ~ \l'... ~ ~ l: ~ ~ ~-\-.. ~ . \II 0- ~ ~~ '" ~I :gl ~ <...; <( co l... .':2 "" c ~ ~ Q ~ ~ '" "- :2' "" "<.:) ~ ~ Q. It ~ '" 111 E ~ '" " Z~' ~ t::(. ~ .'" , '0 .... ~ N "- ~ c .!!! l3 ~ '-'!l III '" Ci .... '" > c. c 00 <( ....:.:.. ~~ I-:l ~ ~ \ C) ~ , ~ ~ ~ ....... Job Location (Street, mile post) (", 2-0 Subdivision It;, 'I/:a..." tfe -If.eit his DOrrIs. 51. Lot 13 Block i z. FOR SAN IT AR IAN'S USE ON L Y: ~System Approved 0 System Disapproved 0 Needs Correction COMMENTS: Signature: ~/;,q~I.V~~~ FOR INSTALLER'S USE: Trench Depth .:J'i" Filler Depth Below Tile ~ L/ Tank Capacity /111'1" Manufacturo- t: tltJe,I-C SO fiNd Measured distance to well from tank 'i? 5' from drainfield C, 0 Scale' J "=. So' \) -J ~~ N PLOT PLAN '1. 3'L 'i 1 M- YJlIII"iiHH 7!td. Ib tk ~/Jocl a/&u tk, ItKJ / . ~ tit Cud! cb za (} ~cUift. t/;(-th ?l&)tM. . tJ~. ~ - - <lJ ~ 1\ '1 ~ " '<'\ . N Oc - d o "" '" <;;P I ... .. ~ Date\:sf2i:a'!?t. 1- (/1 -1 '- c;.. ~\ INSTALLATION RECORD AND CERTIFICATE OF SATISFACTORY COMPLETION When signed by the County Sanitarian, this certificate is evidence as per ORS 454.665 of sat- isfactory completion of a subsurface sewage disposal system at the above location. Return this form to: Permit Processing Section, Department of Environmental Management, Public Service Building, 125 East 8th Avenue, Eugene 97401 C55.11