HomeMy WebLinkAboutPermit Plumbing 1994-5-17
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J".'/ MUST BE IN BLACK INK lo,m c55-11
Permit No. 1oS, - 7'7 Twnshp. I IF Range C> L . Section f9C. I? Ta~ lot /f~.o
Standard System i)t Alternative System _0 (Specify Type) ~...., ~lJ~J),6~ J 1.-+..- - I .
Job Location (Street Address) :J ?.J 7 ~ /.2d, e. ". .
Supdivision/Partition # tY II" Parcel. Lot ~ Block .
DETAIL SYSTEM PLOT PLAN AS CONSTRUCTED
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USE BLACK INK ONLY if
FOR INSTALLER'S USE: Trench Depth ;:J.[ If GraveJ,Depth ~ow Tile_sr-
Tank Capacity ~~t\ Manufacturer ,.... -. U.. ,,;. .~ l..."lul>..
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Measured Distance from Well to Tank <"'l From Drainfield -;:"'\ I(nal Length of Lines :> J ,\
COMPLETE THE FQLl.QWING IE: A PUMP WAS USED ON THIS INSTALLATION: . I ~
I {installer's namer<r..c.......... -'. ~ certify that a (Mfg.) . (Model No.) 'Po~,'" Pump
and Mercury F~ S'(iitch (Mf~ ~d No.) 0 ~ have been installed with this sew~e installa ;"nJ
Signature ~\\ \\, ~ Date ~ - (Z - '-f...i.-
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FOR SANITARIAN'S-USE ONLY:. !?'System Approved 0 System Disapproved 0 Needs Correction
COMMENTS' ~ 14"'-'/~ .<:-/../"__:4
System Capacity 4Lib
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Date
Date .J-17-9j
gal./day Signature
INSTALLATION RECORD & CERTIFICATE OF SATISFACTORY COMPLETION When signed by Ihe County Sanitarian, this certificate is evi-
dence as per OAS 454.665 of satisfactory completion of a subsurface sewage disposal system at Ihe 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.