HomeMy WebLinkAboutPermit Septic Tank 1995-10-11
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VICINITY MAP
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Permit No. !? 3J=-- 9J. Twnshp. -I-fr Range.6"3> Section {;):J.-
Standard System 0 Alternative System rp. (Specify Type) c;'Auo n/...r~f!..
Job Location (Street Address) tqg /JOP..eJS S r <;1'19..0
SupdivisionlPartition # Parcel . Lot
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Tax Lot _ ~ a"
Block
USE BLAj;:K iNK ONLY I'
FOR INSTALLER'S US~: Trench Depth :2 JI- Gravel Depth Below Til" ~
Tank Capacity _/"iDD Manufacturer WILLA l'1e-rrlF 6-JlAYSroM;:-
Measured Distance fro ell to Tank /00 I From Drainfield /00 I Total Length of Lines /"-0.
COMPLETE THE FOLI-OWING IF A PUMP WAS USED ON THIS INSTALLATION: ' '
I (installer's name) 1/ RLlt)EII' certify that a (Mfg.)~RV""OfOS (Model NO.)~D"" 3C>C'> Pump
and Mercury Float)i1witch ~Mfg. and No.) oRerJ (0 have been installed with this sew;~lst~lation.
Signaturp 1/ ~ / Date /93
/
FOR SANITARIAN'S US.~9~LY:
COMMENTS: /$/_ /~~f
p.a I"~ hI I,~
i I . (' "'l'pystem. 9rrected Datp
System Capacity~i,(~ctJ gal./day Slgnatur~-_":?~ Date /0 jaj'lr:>
INSTALLATION RECORD & CERTIFICATE OF SATISFACTORY COMPLETION When signed by the County Sanitari~n. t~is 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.
~stem Approved
D System Disapproved
o Needs Correction
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