HomeMy WebLinkAboutPermit Plumbing 1989-11-6
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I understand that the information contained
on the date of investigation only.
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APPLICANT'S NAME (please print)
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o COMMUNITY WATER SYSTEM (name): U G,q - c5PFLO
~INDIVIDUAL WATER SUPPLY:
in this report signifies the condition of the water supply
j)tJ.t.-..J) ~ !:i?OJner
~.' (f) Gan4..~ 2? ~ ~ 1/- <1--6-'7 ~ Agent
- 0 APPLICANT' 5 SIGUATURE -, . DATE 0 Buyer
o Approved
~/7~-/7
, 0 Not Approved
Construction
Inspection
Requested
o
~
~
Complies wi th
Accepted Standards
Does Not Comply
(see comments)
Bacteria , .J
L. .' /)t.A.-t~
o
~
~
o
o
o
o PLOT PLAN ATTACHED
D INSPECTION CHECKLIST:
1, Pump, Size
~~'
Type
2 _ Sanitary seal present? 0 Yes 0 No
3_ Height of well casing above ground,
4. Is there a proper vent and screen on well? 0 Yes 0 No
5, If a spring or other surface supply, is it properly developed and protected from
sources' of pollution? 0 Yes 0 No
6, Is there a well log available? 0 Yes - Include with report, 0 No - Indicate
presence of seal material and type,
7',' ,
Is the water supply treated; i _e., chlorination or filtration? 0 Yes 0 No
If yes, describe and note that same must be of raw water (before treatment),
8.
Is the water supply located
listed is suspected? Check
o Quantity limited_
If any of the items above are
in any geographic area where the presence of the items
those that are present, 0 Arsenic 0 Salt o Sulphur
Date of tests,
present, have tests been conducted?
Results of tests,
DYes
ONO
COMMENTS:
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. /' V' ~ignature of ~itar1an
OF PLANNING & COMMUNITY DEVELOPMENT
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Date 6f On-Site Investigation
LANE COUNTY DEPARTMENT
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I LANE COUNTY DEPT ENV MGT RECEIPT ~ 317689 DATE 11028~
. APPLICANT ALLEN, DAVID ADDR 1085 LAUREL AVE., SPRINGFIELD, OREGO"
TL~ 1802061310300 SUBDIV LOTDLK
NEW BLDG TYPE USE R BDRMS 0 UNITS 001 STORIES . ~BLDGS 001 PHONE 485 5005
. OWNER NME ALLEN, DAVID ADDR 1085 LAUREL AVE., SPRINGFIELD. ORE GO.
CODE APPL NO ACTION DESCRIPTION SQ FT 'UNIT COST VALUATION FEE DAY~"
BP '"
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BP A
BP
eBP
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.MECH '
SUR'
PCK
eLR
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~FIX/BATH :
SWR:
FT. WTR:
MECHANICAL FEE
STATE SURCHARGE
PLAN CHECK FEE
FT.
RAIN:
FT
.
5;(
25i:
LC 317689 WELV
80.00
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CATG:
eSEQU:
r'h TAKEN
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APP
1
BY RLH
RA
FP SDS' SI
2
PCK
OTH
ISS
3
DEPOS IT **
1.
80.00 CK
EST. COMPLETION DATE
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