HomeMy WebLinkAboutPermit Septic Tank 1996-6-27
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MUST BE IN BLACK INK
Permit No. 1'-I9S - 9 <:a Twnshp, 17 Range (")~
Standard System B"'Kiternative System D ,(SpecifX Type) __
Job Location (Street Address) ~ll GAQ~
Supdivision/Parlition # Parcel
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form c55.11
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.DETAIL SYSTEM PLOT PLAN AS CONSTRUCTED
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VICINITY MAP
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USE BLACK INK ONLY /.
FQR INSTALLER'S USE: Trench Depth _,~ J" , Gravel Depth Below Tile ~/A
Tank Capacity /111tJ Manufacturer ~mAl(., '.
Measured Distance from Well to Tank YA From Drainfield "'/"'1_ Total Length of lines ~~'
COMPLETE THE FOLLOWING IF A PUM WAS USED ON THIS IN{iTALLATION: "
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,
Signature Datp
FOR SANITARIAN'S USE ONLY: ASystem Approved
COMMENTS:
D System Disapproved
D Needs Correction
,2 ~p~orrected . Datp
galJday Signature ~_ 7>---. Date "',/','7';f.'
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INSTALLATION RECORD & CERTIFICATE OF SATISFACTORY COMPLETION When signed by the County Sanitarian. this certificate is evi-
dence as per ORS 454.665 of satisfactory completion of a subsurface sewage disposal system at the above location.
System Capacity
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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.