HomeMy WebLinkAboutPermit Plumbing 1998-4-13
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, ,'~./ ~UST $ IN BLACK INK ,_) 101m 055."
Permit No, / om - 9 t'I' Twnshp, J 7 Range 03 Section ;2...,>, 1 ~ Tax Lot 8'1 <Xi
Standard System 0 Alternative System 0 (Spe~ify Type).... 1!..IDOd-, '?!: ~ 1
Job Location (Street Address) .2.10.4:> 1..0,.,., o"-~, '!.'f, ~ p""'-J'I'"r J}
SupdivisionlPartition · Parcel Lor Block
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,"--USE B49K INK QJlILY ----
FOR INSTALLER'S USE: Trench Depth '5 '. ,Gravel Depth Below Tile
Tank Capacity , Manufacturer 7H~} /-fA"'" 1-1"'>" ,
Measured Distance from Well to Tank, ' " From Drainfield 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 ON~y:'b(System~pprove~, 0 System Disapproved
COMMENTS: ^ JP:UJ /.....1 Z{JP- uti JL-C-f /?
. ' / 0 ~..o,L :11'ed Date,
System Capacity '14.tj) gal./day Signature .. ~(7 Oate
o Needs Correction
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INSTALLATION RECORD & CERTIFICATE OF SATISFACTORY CO~TION When signed by the County Sanitarian. ~his certificate is evi.
dence as. per QAS 454.665 of satisfactory completion of a sUbsi1r'fac;-sewage disposal system at the above location.
To request inspection. relurn all three (3) copies oflhis form to: Lane County EnVironmental Health Services. located in the basement of the
. ~,UbliC Service Building. 125 E. 8th Avenue, Eugene. OR 97401.