HomeMy WebLinkAboutPermit Plumbing 1983-10-5
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MUST BE IN BLACK INK 'DIm c55-11
Permit No. J /,/Z - <f:J _ Twnshp. 17 Range _rJ:J' Section 2f':' f-I Tax Lot I:?L
Standard System ~ Alternative System 0 (Spe.cify lype) _ ._ /.' ~
Job Location (Street Address) 7..t.c.'S ~~.R~~ ~ .
Supdivision/Partition # Paitel Lot 7 _/F' ck
DETAIL SYSTEM PLOT PLAN AS CONSTRUCTED
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USE BLACK INK ONLY .-
FOR INSTALLER'S USE: Trench Depth .::; q Gravel Depth Below Tile t::~ I
Tank Capacity /JIhO~ Manufactur"! l/h'/,1.",,~ t~ S'17""~
Measured Distance from Well to Tank <3 A7-y_ From Drainfield ,,..,.rfe_ Total Length of Lines~ 0
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.
Signatur" Datp
FOR SANITARIAN'S USE ~NLY:~~~~m Approved /70 Syslllm Dis)1pproved _p Nee9s Corr~xtion
COMMENTS' ~ (Il6..l..h: q _... ~q.v_ . ..YA&tl.P~_ _ ~ _~_~~~
......"rt7-"7'.j;...~, ::._~ ou 1#A?JU' ~ ~~;:1.Cc;;rected Datp
System Capacity ----.1"'"'rrl gal./day Signature _ --'><7 ~~ Date, ,(0 _ ~ ~P.-7
INSTALLATION RECORD & CERTIFICATE OF SATISFACTORY COMPLETION When sigKd by the County Sanitarian, this certificate is evi-
dence as per OAS 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. 6th Avenue, Eugene, OR 97401.