HomeMy WebLinkAboutPermit Plumbing 1996-2-22
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. SEWAGE DISPOSAL SV'S'PEWi'ASEBHIL T" PLAN
p~ to tho requi'-ementSwithin OAR 454.665. OAR 340-71-170 and OAR 340-71-175. the system WlstaIlef afldIOfthe pecmittee mustnolifythe department of - ',. ..'- alQuality (or
its authorized AQent) when the constn.dion, altemtion or repair of a $)'Stem for~ a pcm'lit was issued is completed (except for 1he-b3d<filling orCCl'to'eMg of the ~ ~-.~-.--..l. The
L.. 'r"" '. ..( or Agent) has scvon(7) day$ topctf<Xm aninspoctioncfthe compkrtod _._~. .-_._. afterChe offlCi8lnotica date. unless the - ....-......-.- (or Agent) elects 10 waivo the
inspection end 8Ulhorizes the system to be badd"dladearfl<<. Rocciptancl aCc:eplanoe at this ~.,_'.._~"_.. form by the .... .....' '.", - (or PQenQ estab&shestheoffdalnotic:edateof)'OtK
requestforthe~inspedion. pif!1KftmmolPt.. nn~~inr>softheform andretumtoLsneCountvEnvironmenl~~ 1?SF RlhA_" F..o:'~'W!_ ~ 974111
SECTION 1: BASIC INFORMATION
Permit # /371/- 9i, ? J
MapfTax-Lot # I <i?-n-::l.CJu,. J. ~ -/606;;).
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To Be Comoleted Bv Installer:
PERMIT ISSUED TO:
Name: .,--. f(. 7t If c. (!. .' Mailing ,Address: <;? 2. 7 .
Property Address: ~& )" ~ en,..l ~. l t - ~\ I .\
TOTAL #: Bedrooms--,- Living Units ~ Ba:;'ement: ~s_ No
WATER SUPPLY:. PUBLIC OOlndividual 0 Community 0 Other (Name)
SECTION 2: Materials List (Identify and list all materials used in system):
. SEPTIC TANK: ~ Con<t'~te 0 Poly 0 Metal . . .
Manufacturer \~ ,\..LCI ",oJ);', ('.~ Total Liquid Capacity ~ 0 0 -C) Qal.
Distance from Dwelling "ft.; Effluent :!lewer ASTM # ~~...s; .Distance from well. 8 ft.
. DRAINFIELD: ~ r.lt ~1\ . C)
Total Linear Feet ~ 0 a ; Drainfield Pipe (ASTM#W /'l"t I P... Header Pipe (ASTM#}.ol 7...J..\l
Depth Rock Beneath Drain LineC'. in:; Depth Rock Over Drain Line.Q....jn.
Distance of WELL from Closest Portion of DRAINFIELO..o
. Mfg./Type/Size of Rock Filter Materia"
PUMP SYSTEM: l':T: .-
I (installer's name). ' certify/that a
(Mfg_) Model No.'Pl!mp and Mercury Float
Switch (Mfg. and No.) have been installed.wit.!! this sewage installation.
(Complete as Applicable): Working Capacity of Chamber oal. Gallons per Cyc1e---9al.
"Working Cap- - . remaining after alarm has activated qal. -
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Signature
Date
7 - I d- -0 b
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. OTHER: (Materials not - ted above)
FOR SANITARIAN'S USE ONLY: KSystem Approved. '0 System Disapproved 0 Needs Correction
COMMENJ::?: _ --7bfc. 7C(.;-Y2(Ft~-a; /~5Uc/D ~gp uzPaA../
~ //lJ<3>~>/'-?YI<; .'~RXJ7 /..Zr7PD~c.-'-rzP7fK/;'
o System Corrected; Date:' / (1 ./ . . System Capacity .4 SLJ
Signature' ~~ . Date ?/'Zc:../tC;
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454 665 of satisfactory compfetiOn of a Subsurface sewage disposal system at the above k>cation.
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Permit # I 3 7 <I ~ 9JL
SECTION 3:
AS-BUILT PLAN OF THE CONSTRUCTED SYSTEM. Show the following: North arrow, septic system
referenced to a fixed poin~ such as, building foundation or property comer. property lines, wells and water lines
within 200 ft., drive or walk-ways, all buildings, property dimensions, streams, ponds, cuts, escarpments (>50%
slopes). lI).elude final grade shots of ends of trenches, distribution box, and septic tank outlet elevation.
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I certify the information provided in this notice is correct.
and that the constn,lction .of this system was in accordance
with the permit and the rules regulating the cOnstruction of
an on-site sewage disposal system. I have tested the
septic tank for water tightness pe'r OAR 340-73-025(3) and
~ found it to comply_
Installer (Please'p~nt) E' "'" t" f.\N vv.l
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(roUe as shown on OEQ license)
Telephone ....,~ L - ~ ~ ~- (
license No. 3 ~ ~ lll... f' '.
Bonding Gol)' ny ~:r-t. ~.(\ 1\ 1\-.
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Signature
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