HomeMy WebLinkAboutPermit Mechanical 1978-10-20
THIS IS A PRELl/ill/ARY IlEPORl WHlcrni 0 (SMOT IIISUIlE THE ISSUANCE OF A FUTUIlE BUILDING PERliIT.
PLAt/S OR EXPENDITURES MAOE It/A Ij,Eh' CE UPON TIllS REPORT ARE AT YOUR OWN RISK, 1 ~
3rJ.;;..,u;. PLEASE PRINT B/li:sCI-25-?'.)" ... '1!;'
If Subdivision - '~ame HI 'II/L/"n"",.. Uk 2. (r;-I1.)l?IIi/(K910lot 1!,j:L Block #l.
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Owner of Property Owner I s Consent
R'.,1r.<L F,'x No. of Sites /g
Name "
l..:3--r,R (:/<Zdl-lNdl-rLl- La'17fZ No. of Acres 4~
Mail ing Address
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Ztf/,-'jO?'R, X..2/'./. ...h-"~_ 7"< -.r 4'Jf:~-./Check
Telephone # Signature of Applicant Date
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for Off Ice
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Use Only
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lode
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Township
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Sect Ion
,Tax LOft No.
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Range
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Proposed Use ~
of Property 11<2-5,''/'''-117''0''/
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Property S,ze
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C T. Numuer SI)CCI.J1 PermIt Arca
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Ye~ 110
UrbanlZlnfJ Area
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Owner Seller
Applicant's Interest Buyer
In Property' Other (Specify)'
Rea I tor
Legal Access - Road Name EXisting Structures on Property
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Is Property W,thIn One Mile of City?
Yes ..... IIhat City? <;y,+r/.
110 - i
Proposed Water Supply
PubliC V D,strlct:
Spring _ Well Other (Specify)'
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Property LocatIOn (DirectIOns) LlZ!!!?i -=I- (Io'sh tZ.r /?/
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When Will Test Holes Be Ready'
MARK TEST HOLES WITH OUR FLAGS
Location of Test Holes on Property
(Date)
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Draw diagram of property shOWing locatIon of any landmarksjnd relationship
these landmarks
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of test holes to
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MAKE CflECK PAYABLE TO
MAIL TO LANE COUNTY
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HEAL 1f1 AllO SAN ITATlON
BUILDING AND SANITATION DIVISIOII, 135 E. 6 th Ave. Eugene, Oregon 97401
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