HomeMy WebLinkAboutPermit Plumbing 1990-5-29
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, MUST BE IN BLACK ~~
Permit No.~/-'10 Twnshp. 17 Range (::5
Standard S~lternative Sys\ll") CLLSRecify TYP/il)
Job Location (Street Address) ."t.. llL~ ' ^tJh'!"" if W> ('foe -'" '
Supdivision/Partition # , Parcel
form c55-11
Section ..10- /~ Tax Lot ~7t3()
Lot
Block
DETAIL SYSTEM PLOT PLAN AS CONSTRUCTED
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USE BLACK INK ONLY
FOR INSTALLER'S USE: Trench Depth '7_4-" Gravel Depth Below Till'
Tank Capacity-I/"",,,,t;~.L,Manufacturer t.u1('L~~ C;~'Tn"-'~ r:h.
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
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FOR SANITARIAN'SV~E ONL.:~: System :!~~~tem Disappro~d 0 N~rection
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o SystelJl Corrected Date
System Capacity_4I.:JV gal./day Signature.:-- ~ ~~ Date J -..l..9 ~9,^
INSTALLATION RECORD & CERTIFICATE OF SATISFACTORY COMPLETION When4(;gned by the County Sanitarian, this certificate is evi-
dence as per GRS 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.