HomeMy WebLinkAboutPermit Plumbing 1987-4-14
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VICINITY MAP
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lane County
Environmental Health
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Installer t , _.... (J)
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License No, '33 '11/::;-
~ing C, omp.<my a.....IAL h .,{-<t".Y..-
"J,fJ!'-d:"" ~ DatSh/5':l,
(Signature of lIcenseel
If Installed By Owner-
ISignature 01 Ownerl
Applicant's Name & Address
Datp
4
form c55-11
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.J!/ //-87 MUST:B!;:IN'aLACK...IN.K ",-
Permit No, ,-7 ta9. , , Tw~shp, /7 ':, R~~/~W\',' 03 '.section.2..~. 1.2. Tax Lot
Standard System 0 Alte~native system~D,(SpeCifY Typel "A/k"", ./..~-
Job Location (Street AddCeSS)!V~ ~14ffiF. ftflsr I+OP.
Subdivision I Partition #.J..c~ f.r ' '1):'1J A'JKE' arcel Lot" If BlociL/
DETAIL SYSTEM PLOT PLAN AS CON~&.~UCTED
J?f'/C:>PEltfV J...11tJ~ /2c'~2 scale~" =~'
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USE BLACK INK ONLY
FOR INSTALLER'S USE: Trench Depth lJ.iI 1/ Gravel Depth Below Tilp
Tank Capacity-J-....""n , ManufacturerJ;)';tf'......tt /1A 1;;;t;..."
Measured Distance from Well to Tank.. - From Drainfiel Total Length of Lines....!."',..,
COMPLETE THE FOLLOWING IF A PUMP WAf? USED ON THIS INSTALLATION:
I (installer's name) f certify that a IMfgl
and Mercury Float Switch IMfg, and No.!
. IModel No,) Pump
have been installed with this sewage installation.
Signaturp
I)atp
FOR SANITARIAN'S USE ONLY: C!l'System Approved 0 System Disapproved 0 Needs Correction
COMMENTS:4l/l.'1' 7~lJiL IIIJ"P6I!rtfJ) , TK-R: DIU,IIlF,61'i) ~'N~'l'''u.E.P l<,AlflIF'''! #I~
f~,r- 1IfL4R(, Me, nur fM..r' ,{A/I>P,u 1161ZV ur'€/) (/J1>/,E)',.rtr)
- n SYstem Corrected
'I:,~, gal./day Signaturp ?<:' 1 ./L..A__
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INSTALLATION RECORD & CERTIFICATE OF SATISFACTORY COMPLETION WherU'gned by the County Sanitarian, this certificate is
evidence as per GRS 454.665 of satisfactory completion of a subsurface sewage disposal system at the above location.
System Capacity
Dato
Date
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