HomeMy WebLinkAboutPermit Septic Tank 2008-5-4
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05/04/2008 21.45 5416833748 RELIEF NURSERY
MAY!Ui!~UU~!FHl Ub:33 PM Staton Comp~nles FAX No 5417269837
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SEPTIC TANK DECOMMISSION
(ABANDONMENT)
Township
Range
Seet;on/1l4 Section
TQK Lot
PAGE 02/02
P,002
1",1'1
If you are COM&cting to an areQ"wlde sewage collection system or you Qr. replacing your sept1r.: tank,
please don't forgEt to properly decotn"'lSsion your Septle system. An utIattended and ffuoantten septle
tank can become Q $erlous danger for everyone's safety. Present Or~ggn regulQtioM reqUlrn you to
prop~rly decommIssion the septic tQnk as descrIbed below Please have thiS for", si9nad by the
appropriatlil: people Qftd ret~rn the completed farm to:
LANE COUNTY SUBSURFACe SANITATION PROAAM
Public Service Sl.uldlng 125 E~t 8TH Ave Eugene, Oregon 97401
No.." of Prop.r1y Owner J(.. It.. f f\....... ~
8-'0 Sc~ J{;r-! 6,,-
.. '" L
J\ 1'2.0 ( ().., _ by....J< fJ "'I'?-..~.. 'F l'\\!i. "'-
(Date) , I (SIgnature of Licensed OperatClr)
.
SeptiC tank located at
Pumped of slud9$ on _
License #
TheseptlctanklocatAd~t e'"10 5r....-tL '\2...~ 'St-
bQckfltled with sand or clBan bank run gravel after b~ing pumpEd of sludge on II {"2..0 ftJ 1 ..
I<.U i)..S;>..:. ( Si4t- e.,....::-(~ (de-. (~-
Slgnatur~ of O~o,.. (1TK1Y bQ OWJ\ef')
~
Oregon Adrnltu$tnltive Rules (OA~) a4o-7t~1.85 [)ec;oml'rusSlonlng of Systems.
was
(Date)
t'4-~ ')
The owner sholl decommission a system when:
a. A saw~rage IY,te"" becomer: Q\I"IIable and the. bUIlding sewer has been connected
thereto, or
b The source of sewage has been perm(lne;ntly ellmlnclted
1.
Prot:edures ft:Jr becomml.s:JI,:)mng:
a Th~ Tank(s), <:;e5spool or seepage. PI''' shall be pllmpe.d by a IIce.nsed gewogB disposal service
to removQI $eptage.
The tank(s), f::Mspool or s"Pdge pit shall be fl\led with reject SQncl. bar run gravel. or
other matllriQI approved by thB Agent. or the contt2.,,~ shall be removed and properly
, disposed
z.
b
H \LMI:l\SANtTATION\FORMS\Sc:ptlc Tonk [)acal1\llllSSloR farm.dDt
Len.: CGunty _$IR1'411S SanltGftjlft ~ tl!$ 15MI' 8111 Ave, a.-mt OR 97~ (64J)6et~D7S4 PM (541) 6IZ-35M?
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810 s ~~
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