HomeMy WebLinkAboutPermit Plumbing 1991-9-20
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-?DJ'\ / .-t:l / MUST BE IN BLACK INK
Permit No. ~ TV ~ - I r Twnshp, J f?' Range 0.2
Standard System M... Alternative System 0 (Specify Type).,,,,
Job Location (Street Address) 1./ CI t.. dtL..<;A>r k21.
Supdivision/Partition # I Parcel
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Section 05, /:z., Tax Lot yt9lYU
Lot
Block
DETA IL SYSTEM PLOT P
CONSTRUCTED
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USE B~fCK INK ONLY ~" tl"
FOR INSTALLER'S USE: Trench Depth ~ Gravel Depth Below Tile 'fo...l-c,
Tank Capacity _ 15co Gi:\L Manufacturer W II.L"M~ l'''f~'I/ S1"ON€
Measured Distance from Well to Tank --.t!/.A. From Drainfield.1l[,+. Total Length of Lines.3tlo.
COMPLET~ T.HE FOLLOWING IF A PUMP WAS USED.ON THIS INSTALLATION:
I (installer's name) certify that a (Mfg,) (Model No,) , Pump
and Mercury Jloat ~WitCh...(Mfgrlnd.NO,) have been installed with this sewage installation.
Signature K '_~. e::.. - ,...,~ Date q -llo.q I
FOR SANITARIAN'S USE ONLY: i!b-System Approved 0 System Disapproved 0 Needs Correction
COMMENTS'
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Date
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System Capacity '1 ~ 0
gal./day Signature
INSTALLATION RECORD & CERTIFICATE OF SATISFACTORY COMPLETION When signed tlyIlhe County Sanitarian, this 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.