HomeMy WebLinkAboutPermit Septic Tank 1991-1-30
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Permit No.f//?-90 . Twnshp. 17 Range rH Section-Zl./, '2
Standard System~ Allernative System 0 (S~cify Type) - A -
Job Location (Street Address)_~ ~J l!CJ/" '" /" r JJ, 51)~"'1'f';,pll/,
Supdivision/Partition " . Parcel ':A IV .[ Lot
form~11
Tax Lot /3&0 .
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Scale
DETAIL SYSTEM PLOT PLAN AS CONSTRUCTED
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USE BLACK INK ONLY
FOR INSTALLER'S USE: Trench Depth CJ ~ (I Grawl Depth Below Tile (A i'
Tank Capacity I 00'0 Manufacturer \. ,\ . Llr,~L J.h {~Il "'1 " l-" "" , _--=
Measured Distance from Well to Tank From Drainfield I Total Length of Lines~"='
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 Date
FOR SANITARIAN'S USE ONLY:
COMMENTS:
'll( System Approved
o System Disapproved
System Capacity
J.f5l:P
Date J J
Date ',3<1 q I
gal./day Signature },
o Needs Correction
INSTALLATION RECORD & CERTIFICATE OF SATISFAGlORY dd'MPlETION When signed by the County Sanitarian. this certificate is evi,
dance 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.