Loading...
HomeMy WebLinkAboutPermit Building 1974-2-21 ~_., , "~~). 'C .' __' , '/u144 f'. . "~~ j; PROPERTY OWNER -~,/ < , ~., -,,~-~~- ~.~,~ ....'- , "~ANE C.TY BUILDING PERMIT OR MOBIL.OME BUilDING rg: MH D MAILING ,ADDRESS 1130 Flllrvlel:J MAILING ADDRESS 6!'l5 fk:Unlcy USE PERMIT PERMIT NO.~o=::~': -', ~~~L-.-"-:'" , -' ,) /27-,7y /.;;L7-7</ PHONE 7l:~_~!:'7 PHONE 34,2-~l:!:.~ [,chI, !lev CONTRACTOR Cui E. ::::::lrry CO. PROPERTY LOCATION - INCLUDE POST OFFICE FlrGt Addition Centennial Gcrdons 1130 Folrvlcl:J Dr. PROPERTY LEGAL DESCRIPTION - METES, BOUNDS 1st A~dltion Centcnnilll Gcrdcns lot 13 Dloc~ 5 TWP RANGE SECTION lJ EUf:cno, Orogon Euscn;, 0 ro~01l 17 03 27, ~, ~ TAX LOT NO. Jl;.-, /Io!o. CODE CENSUS TRACT APPl. NAME & MAILING ADDRESS FOR MOBilE HOME PERMITS ONLY No. of Bedrooms EXISTING STRUCTURES ON PROPERTY C.:;. Ct:srry CO. Cl-Jf:ll in!! LEGAL ACCESS TO PROPERTY , Folrvic~J Dr. PROPERTY SIZE - FT. WIDTH DEPTH AREA STRUCTURES TO BE BUILT THIS PERMIT Connect to Existing Sewage System D New System D TYPE CONSTRUCTION SQ, FT, :# BORMS VALUATION flcom ;.d~iticn (Fcmlly r=) Frcmo 3G6 CJ J 2 ~.3~2 (Sea Scp,lecent for replccC"-ent of drainllno) SEWAGE DISPOSAL PUBLIC 0 BUILDING WASTE DISPOSAL PLUMBING PLAN REVIEW PARK TRAILER SEPTIC TANK 0 OTHERD .29.CO FEES PLUMBING INSTALLED BY OWNER 0 OTHER, NAME WATER SUPPLY PUBLIC Y0 D OTHER 13.00 ..... MIN. SEPTIC TANK CAPACITY WITH D1ST. BOX: GAl. $ 42.CO COUNTY BUilDING & SANITATION SPECIFICATIONS DRAIN FiElD REQUIRED TOTAL lIN. FT TRENCH WIDTH FT. OR SQ. FT. Our rocorc!s indlccto thClt the prc;losod ;::ddltil:ln is located dlrGctly OVGr ene of ~ho SC~J':Sc ~Is~ogal SyztCD drolnllnes. C~:;.y - POiT.llt sl!;J,Icr.::onted to 1HJ1L:co dr.)lnl inc. TYPE OF STRUCTURE OCCUPANCY ...ZONE PUBLIC UTll. EASEMENT 5 [) BLDG, SETBACKS _ FT. FROM CTR, OF ROAD RIGHT OF WAY USE CLASSIFICATION FRONr':-c SIDE INT. 5 SIDE EXT.- REAR 7 feet ?ul>lIc tit 1I1ty Ecs~7.Cnt AUTHORIZED SIGNATURE - DATE DATE Is/J.E. BOGS by C. HJrbiJugh John Shook 2-21-7l:, slf BLDG" PERMIT - WHITE OFFICE COPY - WHITE COUNTY TAX - PINK PLUMBING - CANARY BUILDING - GREEN SANITATION - GOLDENROD Construction to comply with uniform building code and county regulations covering plumbing and sewage disposal. All buildings require a certificate of occupancy before being occupied. (See Statement on Reverse Side) (POST THIS PERMIT ON MAIN BLDG. AT SITE) LANE COUNTY, BLDG. & SAN. DIV" COURT HOUSE, EUGENE, OREGON 97401 FORM =C55-13 " .'~ , . ;, ''''''-f . ,. -< .~., " )! SUPPLEMENT TO BUIlDING PERMIT NO. ~,,'-.'- . Lane County, Oregon . lei ,:/( .; j/ 0; OWNER 1./ 1/ /' f' I ~~'! ~_'!' ..-, " I i/ . / ~ r ;z......t.-/- MAILING ADDRESS 1/. j' ./ ~'-/.I'/ ;1 CONTRACTOR ! , t/. r' 'Ih'/"L,,. ._ ,:1. MAILING ADDRESS ~ PROPERTY ADDRESS ."'-/ ::, ." /- ,.,' l ,:!{~. ? 'IllII' ADDITION: r " I . ,." .:., ,'. D CORRECTION: , ' , '. 1 " [--- ; , . ,/ ..;,~~ '" -'_1'( -(,. ,( /" '.-/ , ~t _,(' 'f?...! ./' I-fi " 1:-1 ( _ / CHANGE RESULTS IN: 0 REFUND OF FEE, OR D ADDITIONAL FEE: BUILDING !t SEPTIC TANK SANITARY CONNECTIONS /.'~ < /) ~ f,. .~_~) ~ '../2:;' J/ ~ [], 0 .Cash Check TOTAL ElATE FEE PAID ! h :'LANE COUNTY DEPT, OF HEALTH & SANITATION Supplement 5 By l . r I/~ ~ ,- . -~ . 1,' N~ _ 1647 " ~ ..J ',,, --;, -' -.., , ,- ~. .\- ~ ,. . , . ~ ,/) " I , / \." ..J. X'."JJ_:" r Ii IJ ",;/ i '.-/"\.A..f.ll../\. ~ , " , ' l.', /.:;J ;.. (.. /." _ /4 t;..t ' J././ L/..,J - . (~ -t:--.. ~ /-;vL ~ _.-? ;' e -. Dat" 'i/-c !,-; ~":,. --; -J" , '/- , *~ / ,. " , .J-....;i.- .. -- - -.-' . t ~c, ,,,,.i::';~~;,,,,,rs ~",;.. u " ': '~_..." i...u, " '/7 ~::- ..- tICJma-~-u-,~(..?j~I!'~4:-Ii,!- t:f/~.: . addre?s~~~~LJ~":'-f' " ~;, TotaI~iUwl:lg'~o...:.' .j'.~1 .~ Ii Yes 0 No)q" ~ ~",..~" WatIlrsc;lillr b,: Mlic SF'=' .~, ~~'~,.l, uaity.yste.- ' .' /",\:' roO:'" Sc;Itic tal4: Dlstaace fnI:D wen .. fc:lt.. No. of COIIlpCIrtQlen.. MUo (0 , &. " TotaIliqaid ...w;;', f"" ' pi. ~ ~ . I.{- ft. laside wid",. 0/, ~ ft. ' ,,~./. Diame~' ft.'UtpIcI~. ft. . , ': 1\',' - Tole disposal field: Dls .' \,..j,.~ IIozL Yes ~,No 0 Oillr ..:" ' leagt!I ed 1iDe. .u...'JL ~'---'-:'ft. '~~"-'~~:, ,;'/.'/ "fee't'. to' TotaIlaaga /.~'" 'ft.' ...... ~~ ~~ L-:. ~ ' . W'1lIlll of tm:cll ' '. .~ It. tbnlst' . ", 7011d 1qlIll" footap. _ ,..:, 39/1 ' ft.' :.-, lot Ii...: FIODt"O Side ~ Rear 0 Dlstaaceb.I_u.s ',.. "ZiA 9.J~ ft. 'Foaodatioo. '/t) , feet.- t T,... of fiI... ....:. ':,1: GnMJ' .2 f).~lul OIW' Depth of filter maieriol beneath iii. ' .DeptlI of fiI... .., . ,'..1_ 0;1" I'L-Gd:::I..' smat~.... ,. "I: . t " .r. If> feet. inches. ~ ',~-' I~.;I. ~,~':- r?-< r'..~,~ , . o~", ,l __ J,,: ,... .= " . 5 ~At , i" t< :.: , ~90(l fcr+-'~ - ,- . ~ :..':'*''', ,\ "',__,..:..'1 ' - , , ;1. ", ':, ' , I..' :" :' ,,:,:', ": .., ,,"\ ,'- J- "-. '. ' ,,-': :,. ..' ," : ,:, ,('/, !J.' ' " - I hO, ,., , . - ,0 ,': I",' - . '. . <.' .. , " I. . , " ,." ,.: . , . ,i' ,'''' f I , ' . ,C':':", ~. . ,;-'; , " I. I , ] :J,' .~ ',< I ~ " 1 ~ ~,~ "1 ',~ ;U '.,~ '~ -p.t '*'. I 'j:-, - , " : ,":- . 'pit- " ' . '/ll~{1 . . .' I" ,I !. '" , ". .' , . " ...... '. . ' ... , ',: ~. ~ ~j ~j . '-j , ! ~'"''-,:,''' ... '. '...: ."i.:.. ~( . Ii.... ." " . ' Dot- /1- .2..1- ~ l FOR USE OF SANITARVONLY:- s,...... ...._ _.Ily will ..... ~ ~. . Rcmarb~-1 - . ."\-1. (.. IJ/.! 4~, I , ,,1., Dot- " - ~'( - L. ~,' , . ~ sua TO RCDICAlI. :,:"..~T D;2 (l 'fj' 4ilz ~ -- .':...--: . - ,'~""~~-:.-:- /:- -,;J" -- - . .,-..L ..;1M....1i.l~, ad A theifo,,! approYed lo~ occuponcy ~p;l~'ed 0 /..VI -Jt(.krl" 0; 4--J" S- L-/'7 -'- ..; .z: z. , 'v' -- ;' ." ~"-- tk~~" ' ' ../:-".,__,:'.". ,LA#~lNT~ '. . .'. '. . . . ISAJUTARIAN. ~'. ~. . " , (- ~ 0' ~ . '. , " - -l'"";~~ ,.;t. .,:'":,__",~ .J '---..---. . ... -_.-.. ..~_.. ;-_.~ ..-~-_._~..~ ..-. --.,- - :o..-:.~,~:'. ......~, t.:...tt ;, ",\;'>~'.;1 ~PI \.: -,;tj':;~ .:rt'''~- .~ii~:J:i~ '''\I~.w.J:;'t;;::~.~ ., . "......' .-..,-,...,.,... ." .,.........,...'..c;:l.-~ ,~ BUILDING SI~E EVALUATION .' i . , Building Permit Appl ication No. 1.5./ c.1-I. 1'20-71/ I T 17 R "{ S 2. '7 ITAY LOT /bc.. L ~SUS TRACT /Snfff, (~trh,'o f 6Ca,ckl1 ( L - rS f? - S APPLI CANT: NI\ME k-vhL ADDRESS ~ ( ) ( ) Site Inspection Pre-Permit Investigation PHONE DATE , - 5 I'" L/\NE COUNTY PLANN I NG DEPARTMENT I. Zoning Ordinance Compl iance (Zone R.A--)' Subdivision Ordinance Compliance NOT app I icab Ie () () ( ) ( ) ( ) ( ) NO YES NAJ1E DIHE , .J. Required Access ( ) ( ) ( ) ( ) (--r-- ~A...9---.. (~ (J--- ( )--'" ( ) - 1- 5(- 7( 2. 4. Building Site (Area, Width, Frontage, Setback) Other (see comments) 5. COMMENTS: - BUILDING INSPECTION SECTION NOT NO YES NAJ1E DATE app I icab Ie ~) 6. Plans Subm i tted ( ) ( ) r ~) }- So i I Stab i Ii ty (foot ings) ( ) ( ) . ~) ( ) ( ) 8. Flood Plain &;;~~ 9. Other (see Comments) N ( ) ( ) ;l-/t/-7t! ; - I COMMENTS: ( SANITATION SECTION 10. Sewage D i spos a I NOT ~W ~ NAJ1E app~i)able(r(~ ~mrQ () () (I) ( )( ) () () DATE J/ibh\ II. Usable Area - ( ) ( ) COMMENTS: OlAf' re.cor"ofs ,,,o//C"afg 7f1af i/;a Or"'....,(O,~ecl I~ Jt> rr'\ +....,( cI..~rel'_-{/_ ('),)p ,,,. 0"'-'.(> ~..p ff,Q ,.:'..-,',i S'p~ 0,/ l-!.ef,~'..i ~/~f')-..J """......)- 4,.-:\ l"P l^'rf"'!.+..e, v-:li.....a\~\'::.s... lll\l\ " ~f'l 13. Other (see Comments) 12, Water Supply acld;f./;l-. clY'D. I"A. ( );; ~,. " TO APPLICANT: ~ Building Permit / Site Inspection; Can be approved. Lannot be approved at this time as indicated on item NO. ~ above. Quest ions and further informat ion on items I through 5 contact the Lane- COUNTY PLANNING DEPARTMENT. Questions and further information on items 6 through 13 contact the Lane County Buildinq <,,,d Sanitation Division. ~i II be held in this office unt'i I yuu can resolve the problems indicated. () Is being returned. () Your building permit application fee is being returned under separate C,de(. Your c9 -1/ ~f~ lllNC COIIN'I Y I'LiINN I NG DEPIIRTMENT 13," ~i)<th Avenue [~st, tu,:/elle, U'''9'''' 97401 "'l"Nt:: Jlj2--1:111 1')1, 2JI LANE COUNTY IlUltlllNG & Si\NITIITION DIVISION 13') Sixth ~V~Il'" East, EII~lel"'. Oregon 97401 I'IlON!.: 31;2-1311 fliT. l{ll - -,---.- --, M55-2S--- ---- .J PROPERTY OWNER " ,"" CONT~ACTOR LANE C~HY ~UILDING PERMIT OR MOBIL~OME BUILDING 0 MH 0 MAILING ~ADDRESS USE PERMIT PERMIT NO: "; ";/ MAILING ADDRESS PROPERTY LOCATION -INCLUDE POST OffICE o PROPERTY LEGAL DESCRIPTION - METES. BOUNDS NAME & MAILING ADDRESS FOR MOBILE HOME PERMITS ONLY No. of Bedrooms TWP APPl. , " RANGE SECTION ) CODE CENSUS TRACT TAX LOT NO. EXISTING STRUCTURES ON PROPERTY '. ), _......._ J '" ('j~ - t . LEGAL ACCESS TO PROPERTY ~\ , , -. ,,' . , ,\ ,~ ,., ~, i..."\ P~C;~ER:ry SI~E~ ~ " WIDTH DEPTH to ", AREA Connect to Existing Sewage TYPE CONSTRUCTION SQ. System 0 FT. :;; BDRM5 "() STRUCTURES TO BE BUILT THIS PERMIT \~'1 \~, ) SEW AGE DISPOSAL PUBLIC 0 BUILD1NG WASTE DISPOSAL PLUMBING PLAN REVIEW PARK TRAILER ,N ~~ ~\- c. S, ~t, ~, \ .....; .~' ,...... ~f )... . ~ ..\'\ ~\. '\ "\... '-, ~ ' _ I).. A t'\...,,,, " \.)~ ''''~._"'... .-',' '/"':.~";~,{...~;~,, \~~,._.. ";' , \\.\\ l"...;....\ ('-I q~'"""'\ '. f\. '\. .- ......... '""- ._-... ,.. ... ~.lo. - <. ,P.luMB1NG\'INSTAllED..:BY,i....~.....-' y: -" .... 'j':',}-. ~ 0-- ~ V' SEPTIC TANK 0 TOTAL MIN. SEPTIC TANK CAPACITY WITH OIS1. BOX: GAL. TYPE OF STRUCTURE OTHERD OWNER 0 OTHER: NAME WATER SUPPLY . c FEES PUBLIC . 0 o OTHER - . . COUNTY BUILDING & SANITATION SPECIFICATIONS DRAIN FIELD REQUIRED , L1N. FT OR SQ. FT. TRENCH WIDTH FT, \ , ','1 .." "" , OCCUP.ANCY ZONE PUBLIC UTIL. EASEMENT FRONT BLDG, SETBACKS u FT. FROM CTR, OF ROAD RIGHT OF WAY REAR , BLDG, PERMIT - WHITE OFFICE COPY - WHITE COUNTY TAX - PINK PLUMBING - CANARY BUILDING - GREEN SANITATION - GOLDENROD FO~M==....~~.q " SIDE INT. SIDE EXT. AUTHORIZED SIGNATURE - DATE l!SE pASSI~lf~TlON " , L ~ I:? '7- 7 tj PHONE ( PHONE x - - - / -/ New System 0 VALUATION o DATE ,Constr~ction to cqmply' with uniform building code and county regulations , ,,, .~~+l~,' ,\cove~n..g\ ~~~~i.ng~ and\ sewa,~e ""d,isposol.~ ,All buildings require a certificate ).~ -...) '~- .of occupancy~oefore being occupled.~~, -:,'- . .. \ \ ' ''; -, - " ~ ,.' :", l (See Statement on Reverse Side) " ,t, C" \ ' ',', '\"'\ - .,~>~",\\', '.\ i.:, _ '. _ :>:-\ :-,') ')" .,,\- (POST THIS PERMIT ON MAIN BLDG, AT SITE) LANE COUNTY, BlDG, & SAN. DIV,. COURT HOUSE, EUGENE, OREGON 97401 , r . . .,.... '. " SITE I NSPECTI ON , ApPROVED C1 DISAPPROVED C1 DATE INSPECTOR REMARKS FOUNDATION INSPECTION ApPROVED f777' DISAPPROVED I I DATE "3'~CJ -J~ INSPECTOR a REMARKS lJ'k'~ ~ 4~" AL' ~ ~ "3-ff''--7~~ c; / r ,( FRAMING INSPECTION ~ ~ ApPROVED ~'APPROVED /7 DATE.J ~ ;/, ',J '7~ 7:SPECTOR ~ - &/ RrMPp1:(4$#tf4- :1-:z~~<I(VL ~ e{ ~.L is..., ...waLP.r'3-:12' 7'1 ~ LATH OR SHEETROCK INSPECTION ~~~--~ti-PI-7i(~ ApPROVED ~I DISAPPROVED L--I DATE , INS~ECTOR ~ ~::::L~1!t~, ,~!::~#~ -uxd&' .. -~--7 4n:"u7-''''-- 1~/R2 A"'..-.L./n-".'Y. V, I i ~ ~~. , FINAL INSPECTI~N ApPROVED ~ DISAPPROVED REMARK 5 / / DATE/- fD v 7 t/ , , ",,,,,,(2 CERTIFICATE OF OCCUPANCY READY TO ISSUE / / NOT READY TO ISSUE ~ DATE INSPECTOR REMARKS _ / A /' (/ /7 r' ~/ ~/-T, { (~/,.{////~ / \ /~ 11 <--v..... -L --= { ;2:<'7-1f /~ //3tJ cfr~ l LANE COU. BUILDING PERMIT OR MOBILE H& . --PERMIT TYPE - BUilDING D MOBilE HOME DOSC REG. # PROPERTY c;,W):jER MAILING ADDRESS , K-r/U./ L/hA/l //-'5j( 7///"--'/1~~--'--') CONTRACTOR / /:..... ~ , MAILING ADDRESS ~ /'4-iL e.~r;,. hf5'~C~~7' PROP~RTY LOCATION - INCLUDE POST OFFICe- .. I !.,r ,;:;;dd ('/~__.k2.L ~.A/"./~ //3)( /-srMd 6.d~~?U~ SEe, TAX LOT # CODe ;27 ~A'.,~ r/~ PROPERTY LEGAL DESCRIPTION lOT - BLOCK - SUBD1V. TWP RANGE j"7 ,.,~ APPLICANT (7/Yl ..e... ~ NAME AND MAIliNG ADDRESS FOR MOBilE HOME PERMIT ONLY Number of Bedrooms STRUCTURES TO BE BUilT THIS PERMIT. ~ f/J~ Od~'hA-YA!>~~) USE APPLICATION PERMIT :#: 1.:1. 7- 7 V PHONE 7y2,--t?d~7 PHONE -::;>V?-"'-l/(/'<; P./,;/>.//71/J , -- J 7.../-,-""/""", , tJ - - , "7-/7,,{/}/,'/..n L-) Wv. ./ -1-..;"::;' /? /I METES & BOUNDS 0 YES !lZ-I---( 0 f..J-( -_'1 ATTACHED 0 NO CENSUS TRACT DESCRIBE EXISTING STRUCTURES ON PROPERTY IF ANY C-r1 ~ ~~ESS TO, PROPERty - ROAD NAME OR # o-';//Z0.../l-'tfL/) &. PROPERTY SIZE-WIDTH DEPTH ~ '? 9'9.3/ AREA Connect to Existing TYPE CONSTRUCTION .....:;I/J/7.47U?~ xiv d'&(J},y?Lv~ - I / ,1-/1, ~/.A---v'~ Jr_',. ~/ ~ - tt r- 'd,/:-, I"7>:.J~ j , PLUMBIN'G INSTAL 'ED BY /J( OWNER 0 OTHERp NAME L-1l44.f!" ~ Lf'1'kJ-L4-----' PLANS FURNISHED FACILITY PERMIT YE~ NO rJ _ YES 0 NOJoi!... SI - TURE OF APJfICAY //1 , /DATE __ _ ~!j.~.b 11~~J7V J?E RE~E1VE BY' I; / TE - ,/'I/?oj,1 PERMIT # .;;:/' / / - /2 7-2Y. ~Y COUNTY BUilDING & SANITATION SPECIFICA'TlONS --,:}7 DRAIN FIELD REQUIRED J./ lIN. FT. TRENCH WIDTH FT. (! OR ~6'ARE FEET I ./ th.$ oraooserl 1'-' () \)-e.r en 11. (OJ ~ cI ro..,h...-I \ :J SEWAGE DISPOSAL PUBLIC 0 BLDG. WASTE DIS. PLUMBING PLAN REVIEW PARK TRLR. SEPTIC TANK 0 $ ,,:J9,/?/? OTHER 0 FEES WATER SUPPLY PUBLIC ~ _OTHER PLUMBING FEES~ ...:::; FIXTURES 9. 0 () /.'5 , .P>~ CASH 0 SEW.sJV CHECK/.[l~NECTION FEE PUBLIC WATER CONNECTION FEE .;1,00 TOTAL Y-:;,Oi) d' ()O MIN, SEPTIC TANK CAPACITY WITH DIS1. BOX: GAl. Sewage System D or New System Req. [l SQ. FT.;:') # BEDROOMS VALUATION - .3t.~~/:1 l/ ~q:J- Ol,\,{" C'ecof'-c!s ;'i--dtr'".fp, -;ha.t ~ 15 /oco.--t-ei c(/~(7cAI'j o j/( l':J<-1'~ I,t S- "'J:),i':))~""hi-ej +0 r'BifD!ac,;. S Ii / J OCCUPANCY f1Z0NE I TYPE OF STRUCTURE BLDG. SETBACKS - FT, FROM CTR. OF ROAD RIGHT OF WAY FRONT 9'0 SIDE 'NT. _~ p:j)~ Ji2GJJ7r ' Directions to Find Property: acidic>, ~ 'ff21ra. i nl /'1qr HLt ~ PUBLIC UTll. EASEMENT REAR YARD USE CLASSIFICATION SIDEt:J.~ PLANNING JU/-:--' I REAR 7 PVE. 1 - 31 ~7 i.jBLDG INSP, JfJ ~g,;l-; iI-7'7P ' I r-- { , COPY I - OFFICE COpy 2 - JOURNAL COPY 3 - AUDIT Form # C55-1Z /~ 0, P"",,,v.:>ElilIiUBSURFACE SEW1\GE' o.rSPOSAL SYS~ Install. Complete top part of form to__% signature and submit both coples with - application. "0 ..~J'.~_ '. " No. Living Units , / Septic Tank: Ft. from well Inside Dimensions: Length Width Applicant Name I Bed.:?ODIs (Exhibit No.1) I Property Address I Baths I Basementx I / Yes_ No_ .A:k'ff-J!... . ,J Permit No. /:;.1-"7.;t Installer's Name Water Supply Community Publi,.)( Other-List_ Steel_ Concrete _ No. Compartments Ft. Diameter Depth Gal. (;apaci t'( Tile Disposal Field: Distribution Box: Yes _ No_ Other Distribution - Type Address R,~ ~j c;: t, t- ~4 -0, , I Total ft. Feet from Well Lot Line Front side Rp.ar Ft. betweenlFi ,ter I rg~~r DePthlbi:J,~r lines Type me in. tite Foundation Mailing Length of Line!. - Ft. l Trench 1. 2 . 3. 4. .'" 5 . 6 . width Plot Plan 'Ulee instructions' : Sq., Depth in. I .~~ ---+---- .-,-., , I I i ; I ,'--'---'1--' ..,,-,-- ,,--.----- ----- ---------,-- ---I--T-+~- --,-- -- ----- ,.-.:_.. ._;_ ....__ + ...1....- _ u , I ' ' I i ~-- - I -t-----]'-- r---- , ------1-- [--+--1-= ,,' ,-- ' ---' --- 1- '~lJ.- ,,-- ~~- '. -.-- , I I i I ! - --------, -- _un' ----j- I I I, ! " , __'n ----, ----I -'1 ---,---ur- ---------- -- 'u____. ,-,-----,- ----- _u_ I 1--1..-' ______~_ _________ --- -.--,+-1- l 1- -- ---- - ---- --- , I I , I ___ 'u _ _,__ __ ___ ~I _ _,__ ___, ___ _ _____ ,___ __ _ ! , _._' ___. ~- ..- ._, ~- -~, -- ---.,i---- ~- --, --- -.-- ,-_ -'_.'._ I , ,--.- .,...-* . . -- ,..---. --- - Date Siqnature Fo~anitarian Use Only: t:l:3' Approved: System Installation o Disapproved: Does not Conform Remarks: Conforms to DEQ Rules for Subsurface Sewage Disposal to DEQ Rules for Subsurface Sewage nisposal Date: iJ~7/7cj J!Y-Ji),,,~ ~ .w'M~ Sanit1'rili'n'" Sicmature ' ' State of Oregon Department of Environmental Quality Interim Form #2 N~~~'kj;;.:c"";i:.f U'<~ - , ., C:;;;~:"H:,",il<<"'~7-i9!12-6Jh.::".l , ,A ~/.. .~1J:7 . "l~ ....' . . "."'-J C~,---<- {,:(;-' /;..'- IV." J., . '.~<A ~-.'r"1 c.,'r-'s' :Ju/li'r ~<J.) J . y- 1\.........,- .....1 1...-L".!~__~... _-r "'- I ...._".. ~ '''''.''' _u..... Jii. ~;- Tc:~1 r.:"'~:,: l:-O-:"J r:";:~ C::l;:::::...:d..:. Cai~;...L C:::::::ol: Yos 0 No ~ \"lat:r st:;;;!y b7: r~t';t' t)-:i:~ V f~~h':~::::1 :j~t::;:t Cc~;nui1ity system ...., ....'c t.." C',~.,' '-~ --'1'/ Fut u.'_":., ('''.1'1'''';''0 of (.--a,'--n- 1<-.; j. (/J ..~...I. \"...\. ........,..... ....... .._. ---I' .... . h....,...~~ _J.p.. ' .... ......... ~,... 1~ T et:1 tiq.:~ (c~:d:r '1,1) ~ co!. In:i~3 le"'llll. _',.r - 'I. 'nsid. width " C ft. 0::::101:, fl. l':;::i:l ":pl~ .~-' fl. Tilo db~:;al f~dd: C:strib::f' t:'?. Yes Jt( No 0 Cl~:, lc":llh e:eh 1m. ~ l _ _ fl. Telol b:l:h /.:? At' fl. Wi~:h cf tre::eh . ~ rt. :re::;1 sq:;:'" f.:olCil3 -~ 9/l fl. Dislance 1;;:1v~, Ii":s ::t., /J ij- fl. ly;:e of fihzr r.:oln;:I: Gi~i:I=--~...l{;l.b",' 01:Scr ~i):~ of Wt=, r:'::1t=r.:l c::r (:!.. I "~~i::c~:3. . .___~_ Sl([TCltl~"_I' . -ft'. : lIlI lino; Fronl O. Sido,~ Roo, 0 Foundalio" It) 1.01. Depth 01 IiIle, motorial benoath til- ~ . . Di,l,me: from; , I Well.IV.1 ,J r /L- fc.I, t~:::::::;t 5 ;j ~ ..-t' :-:-J9cc H:j:l-- -- - - - \ __ _ L N:~ .!J~!::j I I I I I~j t I (, l\.. I r . +)" ~ ~ 10' l' -, 1:.1 l. tc :~t IS' ;l.i' '- /1) f.ol. inches. I I I I (' I ( 'j , , f:;.1I T1\ a( ". ;- 'Z, ...l) il;~ 10' . ~ I J' l A' Tl l" Z. I" l' j I C! ~!):! 70 r;:~:c,\Tt r:C,lTl:aLY CI~:CT2 ,,1. Dcl. / / - ..2. 1- '/. 3 s:~"o::;" 2! r-::( 9- 1-1 !LU""'; -------------------- ---------'---/J ------------ FOR USE OF SMIITMIMI O::lY: _/ / J. Sy>lcm c~p:,:"::, "i:1 f\l~::1 r.:II..-J I""cti,~ ,,:::f::~r"YI o,1j, lheda", opproved for o<:cuponc(~'ap~raved 0 Rc::::rks::'-~C1 , &~ ,..:I..Ll /"".A<? /J..-1' __1< Z-------/ <-I ..?--i" S?-? ~ z /, ...'\-1. ~ l) f! .e.~j/dLb__L.,.A-. ~- - \~' " /. / , 7. I LII"iJ COl?:Y HEi,H~ DEPARTMENT -q-' Dol_ " - )...<( - ,~ ""'\ ~ ~ DANITAnlAN . . .i' .' . :~...-: ! . c~ '-.- ~.. . , ,.' , .