HomeMy WebLinkAboutPermit Plumbing 1981-6-18
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VICINITY MAP
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JAc<scr I "XCAV/,TlNG SERVICE
375.JO v,:, \lL.';..CE C;;:;:EK ROAD
SPRINGFIELD, OREGO,~ 97477
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!Title 8S shown on D~censel
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Telephone
License No. I t, I ~ I.)
BJrding Company ~~ ~
,fJ,(h~ e~Lh->.JDate~-/e.81
lSignatureol Licensee)
If Installed By Owner-
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lSignature of Owner) _ ...1
Applicant's Name & ~r~s ~11.L'
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MUST.BE IN BLACK INK oZ. :3 form c55-11
Permit No. /LilY-XL Twnshp, /Y Range t?e:. Section () ,,') Tax ~ot, ~ /~6'd
Standard System]:8'. Alternative Syst~m 0 JSpecif.\( Typel p~ ~ - d~)!.':U1r. '!;ff~1
Job Location (Street Address) ::;i:r C1'/~..,) ~Ar,O,op .t!'Ann/. ,~/?P/Ar:~;- ([~ 971/?)
Subdivision/Partition # 1) Parce' . _fot 8W1ll0c1' ,
DETAIL SYSTEM PLOT PLAN AS CONSTRUCTED
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..J.. USE JlLACJ, INK ONLY
FOR INSTALLER~S U~I;: ~::rTrench Depth 30' . Grav:1 Depth Below Til"
TankCapacltY~JAf.I Manufacturer .A~-r-.:l d... ":J-'" ~i'-'.A!'I.J
Measured Distance from Well to Tan~ From Drainfielrl ,Total Length of Line< /50'
COMPLETE THE FOllOWING tF A PUMP WAS USED ON THIS INSTALLATION:
I !installer's namp, certify that a IMfg)
and Mercury Float Switch IMfg. and No.1
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IModel No.1 Pump
have been installed with this sewage installation.
Signature
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FOR SANITARIAN'S USE ONLY:
COM ENT~:
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o Needs Correction
Dat" .
System Capacity 'J,['J:) Date~
INSTALLATION RECORD & CERTIFICATE OF SATISFACTORY COMPLETION When signed by the County Sanitarian, this clI'rtificate is
evidence as per ORS 454.665 of satisfactory completion of a subsurface sewage disposal system at the above location.
Heturn tnls torm to: !:lUIIOmg ano ~anltatlon UIV., Uept. ot tnvlronmental Management, 10cateO In tne oasement ot me
Public Service Building, 125 E. 8th Avenue, Eugene 97401.
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