HomeMy WebLinkAboutPermit Plumbing 1991-12-13
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{. MUST BE IN BLACK INK
Permit No. ,;J 76,., - ~ Twnshp. /7 Range r).2 Section
Standard System )i!. Alternative System D (S~ ljpe) . Je.I
Job location (Street Address) .2.X'?! ~ LJ..U.i;~. .
Supdivision/Partition " Par~1 . Lot
/9...1 L Tax Lot
form cS5-11
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DETAIL SYSTEM PLOT PLAN AS CONSTRUeTED
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'HAVE '"'''' llLYINSPEClEDTltl!,-
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USE BLACK INK ONLY I' (f
FOR INSTAllER'S ':!SE: Trench Depth ."2 0 ,( hGravel Ollpth Below Tilp \0
Tank Capacity .I" [l ~ Manufacturer. \ '\ . I I ~[1.. ~ n.. '1 ) t-..,-, L.
Measured Distance from Well to Tank \(] . From Drainfield A 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.)
and Mercury Float Switch (Mfg. and No.) have been installed with this sewage installation.
Signaturp . Dat"
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FOR SANITARIANJ2~ ONLY: ~st.em~proved _~D Sy tern Di~approvnd D Nlljlds C?rrec~
CO.MMENTS' A? ~ '~ P ./. _ ..r _ f/~ ""'_~ 7'/?II..AAUI-;; "'4
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-:: . LJ System' Corrected Dat"
System Capacity '1.$7) gal./day Signature... ~ _ .0 '"'j.. _ Date /77'.7-f/
INSTALLATION RECORD & CERTIFICATE OF SATISFACTORY COMPLETION When si by the County Sanitarian, this certificate is evi-
dence as per'-oF;lS 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.