HomeMy WebLinkAboutPermit Plumbing 1991-1-24
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VICINITY MAP
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7\ MlJST BE IN BLACK INK
Permit No, Lio '1 'I- - q V Twnshp, II Range 02.. Section. /, Cf
Standard System )Xl., Alternative SysteJ!) 0 (S~Cify Type) --
Job location (Street Address) ~8S() _ rtl2..V\~. KO., ';;::;',~oJ.
Supdivision/Partition # Parcel Lot
form c5S-11
Tax lot 700
(1'7</.77
Block
DETAIL SYSTEM PLOT PLAN AS CONSTRUCTED
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USE BLACK INK ONLY ,-
FOR INSTAllER'S USE: Trench Depth ::1' Gravel Depth Below Tile ~-g"
Tank Capacity_'()DO~ ManufacturerWILU.I!1,4'J"7lE' ~ ~
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,
Signature~~hA' ./ -(,g(./!'''' - I Date f..:::J;L.q/
FOR SANITARIA!)I'S USE ONLY: tW:i System ~pproA'ed I:;J System D~pproved OilNee~s Corr,!lction
COMMENTS:_IL.-, , L ?V~ 'If oJ If...a.-.. cf-~, Y./h. ~Ztp"1 ~
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;,e,:..o, 7; u:J'./.I-f/"'A'T/-:J.'7-4( JvE~)_ 0 Syste afrected Date I-~ '1-<;,
. System Capacity ~rn \ gal./day Signatufe/_a ',v ;,-- Date ..2-/<i'_Q/
INSTALLATION RECORD & CERTIFICATE OF SATISFACTORY COMPLETION When Si~ 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.
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.