HomeMy WebLinkAboutPermit Building 1975-6-25
"
r'
LANE co~.h
BUilDING D
BUILDING PERMIT OR MOBILE OME
MH D(X
MAIL!!::!.G ADDRESS'M"
(00 WEST
177;-J 3;;;5-15"
\ (-. (u'r
"
.
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USE PERMIT
PERMIT NO
t.-::-t 325-15
PROPERTY OWNER ~
a.1UCE FLETCHER
SPR I NOFl EL 0
OC1EGON
PHONE
CONTRACTOR
E~ERALO TRAILER SALES
MAILING ADDRESS
SPRINGFIELD
147_8111PHONE
PROPERTY LOCATION - INCLUDE POST OffICE
FILBERT GROVE SUDOIVISION SOUTH 2NO STREET TO HARBOR
SPR I NGV I ELO
206& HA1'on Q IVI
PROPERTY LEGAL DESCRIPTION - METES BOUNDS 41
5TH ADDITION FILBERT GROVE LOT
BLOCK 3
TWP
16
RANGE
3
SECTION
II, ::l.
TA""T ;0. ~ CODE
::z. .: _.--'f7 ~~
EXISTING STRU6u~ -;'N
NONE
LEGAL ACCESS TO PROPERTY
~Olo(P HARElOR DR I VE
PROPERTY SIZE - FT
CENSUS TRACT 11-186
""
APPL
NAME
BRUCE FLETCHER
PROPERTY
&
SAME
,
MAILING
ADDRESS
FOR MOBilE HOME PERMITS ONLY
No of Bedrooms
STRUCTURES TO BE BUILT THIS PERMIT
WIDTH
DEPTH
AREA
Connect to EXisting Sewage System D
TYPE CONSTRUCTION SQ FT :;:t BDRMS
New System D
VALUATION
P.RMIT TO PARK MOBILE HOME
2
P.RtlIT TO INSTALL SEWAGE DISPOSAL SYSTEM
SEWAGE DISPOSAL
PUBLIC 0 SEPTIC TANK 0
BUILDING ~
WASTE DISPOSAL
PLUMBING
PLAN REVIEW
PARK TRAILER
lj!SURCHARGE
TOTAL ~
FEES
PLUMBING INSTALLED BY
OWNER 0 OTHER NAME
WATER SUPPLY
OTHERD
')9,00
4.00
PUBLIC 0
o OTHER
~o.oo
, ,04
lj4,04
COUNTY
BUilDING & SANITATION SPECIFICATIONS
MIN SEPTIC TANK CAPACITY
WITH DIST BOX GAL 750
DRAIN FIELD REQUIRED
UN FT 150
TRENCH WIDTH FT
3DEPTH
OR SQ FT
390
STAY 100' FROtt \tELL WITH ALL PARTS OF SOS:
TYPE OF STRUCTURE
OCCUPANCY
.
ZONE
PUBLIC UTlL EASEMENT
~; -l
SLDG SETBACKS FT FROM CTR OF ROAD RIGHT OF WAY
USE ClASSIFICATION
FRONT 45'
SIDE INT 5 t SlOE EXT
AUTHORIZED SIGNATURE - DATE
REAR
5'
/s/ J. E. Boss BY C HARBAUOH
SPOOK SANITAC1IAN
DATE
6/25-75
BlDG PERMIT - WHITE
OFFICE COPY - WHITE
COUNTY TAX - PINK
PLUMBING - CANARY
BUILDING - GREEN
SANITATION - GOLDENROD
Call 687-4065 to schedule all required inspections All construc-
tion shall comply With Uniform BUIlding Code, D E Q standards
IMPORTANT for subsurface sewage disposal and county regulations covenng
plumbing All bUildings requIre a certificate of occupancy before
being occupied
(See Details on Reverse Side)
FORM = C55 13
(POST THIS PERMIT ON MAIN BLDG AT SITE)
LANE COUNTY, OEPT OF ENVIRONMENTAL MANAGEMENT
COURTHOUSE ANNEX, 135 EAST 6th, EUGENE, OREGON 97401
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~f!y/~\ T RO'3 S/\-"2.2..TAXLOT::e:4:>O
SUBDlv~SION:
NO. Mijjit2,<!S-,/ LOT: BLOCK:
__ 'APPLICANT -\-I~-er
DATE
Not
Aeplicable No Yes
Zoning Ordinance ComplIance' ZonelfAL,~~() ~) 1 6,
SubdIvIsion Ordinance ComplIance () () C)
Requl red Access () () ( )
Building SIte (Area, Width, Frontage) () () V)
Other (see comments) () (),
.
BUILDING,SiTE EVALUATION
/ '
~.BUILDING PERMIT APPLICATION
() SITE INSPECTION
PLANNING DIVISION
1.
2.
3.
4.
5.
COMMENTS:
PLANNING OIVISION ACTION PENDING: YES\ ) NO( ) APPLICATION#
BUILDING INSPECTION DIVISION
Not
ApplIcable
~ 1
d~
No ~e
~)
( ) (
( ) ( )
( ) ( )
7. Plans Submitted
8, Soil StabilIty (footings)
9. Flood Plain
10, Other (see comments)
COMMENTS:
WATER POLUTION CONTROL
Not
App 1 icab 1 e
( )
( )
No Yes
~) TT
( ) ( )
]1, Meets Department of Environmental
Quality Standards,
12. Other (see comments)
COMMENTS:
CK'D BY:d~~~ (1"\. h-s-
Setbacks from cll of roa~
Front 46
S l"eIe-cA,en or
Setbacks from Interior lInes.
Side ~
Rear ~
CK'D Bytf;:l~t-.tf'?~
DATE
CK'D BY~~ &(2)/~r
l~ DATE
TO APPLICANT:
(Your Building I Site Inspection'
~ M- Can be approved,
r,v~ 1-) Cannot be approved at this tIme as Indicated on Item NO, above,
t) Questions and further Information on Items I through 6 contact the LANE-
COUNTY PLANNING DIVISION, QuestIons and further information on Items 7
through 12 contact the LANE COUNTY BUILDING AND SANITATION DIVISION. //
( ) Will be held in this office until you can resolve the problems Indicated,
( ) Is bel ng returned, ,
( ) Your building permit aEP1IcO!l!.i2!,_~fj"'.._,_~",in.q..returned under se'2.ill:i'te cover,
IJcPARTMENT Of ENVIRONMENTAL MANAGEMENT
135 Sixth Avenue East Eugene Oregon 97401
PHONE: 687-4065
LANE COUNTY PLANNING DIVISION PHONE: 687-4]86
C55-28
.
..;
Dote"
JUNE 2') lQ7')
PermIt No
.
CURB CUT
MI-I ':)?~..,c:;
..... .,.~
PERMIT
IN THE BOARD OF COUNTY COMMISSIONERS OF LANE COUNTY
WHEREAS, the attoched applicotlon has been fully considered by the Board of County Com-
mISSIoners of Lane County, and It IS the opinion and ludgment of the Board that the said opplicatlon
should be granted, and that a permit should be Issued, now, therefore, It IS hereby
ORDERED, that a permit be and IS hereby Issued to
SPRINGFIELD OREGON 97477
or constructing the following facility
BRllr,::,
1:". .,.~,..u...."
- -
;-8o-.JNS?T ~" ~:~.c~T
for placing, bUIlding
FILBERT GROVE
5TH ADDITION
Lo T 47 BLOCK ~
upon the rlght-of-woy of County Road No , Mile Post
In strict conformIty to the exhibits ottoched hereto, ond sublect to all terms, conditions, agreements,
stipulations and prOVISIons contained In the application and permit, the Rules ond Regulations Gov-
erning FacilitIes to be Permitted upon County Road Rights-of-Way, os set forth by the Lane Man-
ual 50 190(2) any amendments thereto, and any other applicable regulations, law or ordinance
Specla I PrOVISIons
2
Drlvewoy wIll be constructed In accordance with the attached driveway approach specIfica-
tions (Drawing M98-50)
Permittee will be responsible for the Immediate removal of all mud, dirt ond debns from the
roadway and right of way caused by h,s operation, leaving the roadwoy and area In 0 neat,
acceptoble condition
3.
SIDEWALKS WILL BE CONSTRUCTED IN ACCORDANCE WITH THE ATTACHED SIDEWALK
SPECIFICATIONS AND DRAWING M98.49. THE STANDARD CURG TYPE SHALLBE
CONSTRUCTED UNLESS OTHERWISE SPECIFIED:
This permIt IS revocable ot any tIme, ond will be strictly adhered to and no work other thon
that specifically mentioned above IS hereby authorized
This permit shall be vOId unless the work herein contemplated shall have been completed be-
fore
,JUNF 2') lQ76
,19_
Expires
.19_
Inspected ond Approved
Approved by 7'rd of C
~Zh
01 rector
Doto
By
WHITE - OFFICE FilE
GREEN - RESIDENT ENGINEER
PINK - PERMITTEE
BLUE - ROAD SUPERVISOR
ORANGE - BUILDING & SANITATION DEPT
YEllOW - REAL ESTATE
c98-79
! I
n
LANE CO....JY
BUILDING'D
" -:: ;f. ... ."-'F'. -.
I.'. ,>; .1
. ,
~U.I'L'DING Pi:~MITOR M~BlEaME
~ ~ wi D~'; .
M:'ILlNG ~DRESS,....
100 "G liT"". ... .!i
'70
'7""....
,.n:,,'
. , ~. .'''''''''''
r
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'.'1 ... e,' .....i.
I . ,.
..... -I
/
, /..-
'PROPERTY OWNER
I &1tltCt fLUCK!/!
USE PERMIT
PERMIT NO.
SP!!lINQfltLO
t.tI~75
~
I,
! . CONTRACTOR MAILING ADDRESS
, ~ E~Il.1.O TRAILeR SA":U. '.: ,.,
; PROPERTY LOCATION - INClUDE POST OFFICE
I ftLeUT lOliovr 5UIlOIVIlIIO" SOU," 2lto "!!lEEf TO HAllnOO
i PROPERTY LEGAL DESCRIPTION - METES, BOUNDS 1.7
5'" AoOITIO" f'LltftT Gft.~1 lOT. 8L.~K 3
SaoftI NGNi'LO
Oltt_
71l7~8711PHONE
PHONE
,.
.
,.
5"1l'II~F lno
2~ HAIUIO. !)lIVE
. ..
'j
;-""\
i TWP
i It\
RANGE
3
SECTION
11
TAX:J.9:r~NO"" ,"
"'." .. . '#... ;~
CODE
CENSUS TRACT 17-lt6
APPl.
allUCf fLItTCII~R
EXISTING STRUCTURES ON PROPERTY
NON!:
LEGAL ACCESS TO PROPERTY
U.'U!Oll 0111 VI
PROPERTY SIZE - FT.
NAME
&
MAILING
ADDRESS
FOR MOBILE HOME PERMITS ON~Y
',No. of Bedrooms.. .,~~ \..'~'~ .... -:;"' ~.,.\~.
STRUCYURES_TO BE BUILT THIS PERMIT
SAllE
WIDTH
t'-DEP.TH
AREA
"
i
'",',. "'"
.. 7. -.
Connect to Existing Sewc"ge System 0
TYPE CONSTRUCTION SQ, FT, ;; BDRMS
N S D'
ew ystem' .:
VALUATION I
Prll/lllT TO PA~1l MoSlLe HQtllIt
~
"
I
.,.PrltMIT T" IN$TALL Sf\lAlK DIIPQl5AL SYSTEM
: I'
"
,.
,
I SEWAGE DISPOSAL
I PUBLIC D SEPTIC TANK
I' BUILDING
,
WASTE' DISPOSAL
,
~LU~BING
,
"PLAN. REVIEW
I.
o OTHERD
$--"
,..00
".00
FEES
PLUMBING INSTALLED BY
OWNER 0 OTHER: NAME
WATER SUPPLY
,
1 i
It
PU BllC 0
o OTHER
PAR~TRAILER
: l;t'lI_C:liAU.
I
TOTAL
3U.OJ
.~
$ . QIJ.1J'f
COUNTY BUILDING & SANITATION SPECIFICATIONS
J.. .
MIN. SEPTIC TANK CAPACITY
I WITH DIST. ~'BbX; GAL I 750
DRAIN FiElD REQUIRED
UN. fT 150
TRENCH WIDTH FT.
3~t"T"
OR SQ. FT.
3'lO
buv lOG' 'R'" lItU, II IT" M.LP""!~W $.: ~ "
'I ~"'L\ ~~ ~ -\~'\' ~ \\\\
TYPE OF STRUCTURE OCCUPANCY ZONE PUBLIC UTll. E~SEMENT
t,~t -t t
,
f BLDG. SETBACKS __ FT. FROM CTR. OF. ROAD RIGHT OF WAY USE CLASSIFICATION I
IFRONT "" SlOE lNT. , ~. SIDE EXT. REAR " ,
, I
AUTHORIZED' SIGNATURE - DATE' . 6/.,.". 75 DATE
, ! !f-I J. !:. 80s. .v C tlAflIIAt.I8I1 .S-t#Mlll 'A"ITA' I All
tBLDG. PERMIT-WHITE
IOFFICE COpy - WHITE
ICOUNTY TAX - PINK
PLUMBING - CANARY
fBUILDING....;. GREEN
,SANITATION - GOLDENROp
. i
. Call 687.4065 to schedule all required inspections, All construc-
. lion shall comply with Uniform Building Code, D.E.Q. standards,
IMPORTANT: for subs,:-,rface sewage disposal and county regulations covering I
plumbing. All buildings .require a certificate of. occupancy before I
being ?ccupi~ . -'-, . I. '\
~?ee. p~~~ails _ on, Reverse. Sid,e) :. \
I
. I... .
FORM:::: C55-13'
(POST THIS PERMIT' ON MAIN BLDG. AT SITE)
LANE COUNTY, DEfT, OF ~NV!RONMENTAL MANAGEMENT
COURTHOUSE AN_NEX, 135 EI>:~T,6th, EUG~~E, O~E~ON 97401 .
SITE INSPECTION
ApPROVED Cl
DISAPPROVED Cl DATE
REMARKS
FOUNDATION INSPECTION
ApPROVED 1-1 DI SAPPROVEO 1-1 DATE
REMARKS
FRAMING INSPECTION
/
AP~/ROVED / / DISAPPROVED Cl DATE
REMARKS
LATH OR SHEETROCK INSPECTION
ApPROVED ~I DISAPPROVED ~ DATE
REMARKS
FINAL INSPECTION .
ApPROVED ~ DISAPPROVEO till 1 DATE
REMARKS 11 If Ad ~L~~' 'J - ;t y ~
CERTIFICATE OF OCCUPANCY
INSPECTOR
INSPECTOR
INSPECTOR
INSPECTOR
/.~ INSPECTOR
1S/~
READY TO ISSUE / / NOT READY TO ISSUE Cl QATE
INSPECTOR
REMARKS
11)1 3JF1.5 ~ 47- )6-:1- f zL~
ff~~"p~
.
,.
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)
-'
Permit No
CURB CUT
PERMIT
IN THE BOARD OF COUNTY COMMISSIONERS OF LANE COUNTY
WHEREAS, the ottached applicahon has been fully considered by the Board of County Com-
missioners of lane County, ond It IS the opinion and ludgment of the Board thot the sOld application
should be granted, and that a permit should be Issued, now, therefore, It IS hereby
ORDERED, thot a permIt be and IS hereby Issued to
for plaCing, building
or constructing the following facility
upon the right-of-way of County Rood No , M,le Post ,
In strict conformity to the exh,b,ts attached hereto, ond sublect to all terms, conditions, ogreements,
shpulohons and provIsions contained In the oppllcatlon and permit, the Rules and Regulations Gov-
erning FacilitIes to be Permitted upon County Road Rights-of-Way, as set forth by the lane Man-
uol 50 190(2) any omendments thereto, ond any other appllcoble regulahons, law or ordlnonce
SpecIal PrOVISions
Driveway will be constructed In accordance with the attached driveway approach speclflco'
tlons (DraWing M98-50)
2 Permittee will be responsible for the ,mmed,ate removal of all mud, dirt and debns from the
roadway and right of way coused by hiS operation, leaVing the roadwoy and area In a neat,
occeptable condition
ThIS permit IS revocable at any time, and wdl be strictly adhered to and no work other thon
that speCifically menhoned above IS hereby authorized
ThiS permit shall be vOid unless the work herein contemplated shall hove been completed be-
forp
, 19_
Expires
,19_
Inspected and Approved
Approved by Board of County CommiSSIoners
By
Dah'
By
Director of Public Works
WHITE - OFFICE filE
GREEN - RESIDENT ENGINEER
PINK - PERMITTEE
BLUE - ROAD SUPERVISOR
ORANGE - BUILDING & SANITATION DEPT
YEllOW - REAL ESTATE
C98-79
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LANE C.
BUILDING
)NTY
n
BUILDING PERMIT
M H n{)\
MAILING ADDRESS,MIt
1i;ll) t.'i!01 '",
OR MOBIL~ HOME USE PERMIT
PERMIT NO
Spnlt~ClI'" 1ti:I..D
0:1,0(.;)
i'(H 3E5-"D
PHONE
PROPERTY OWNER
O!lU~(t F'l..eTC~e:n
CONTRACTOR
~~cnAlD TPAIl..l!R SALaQ'
MAILING ADDRESS
I 7"1_.n711PHONE
CP~tI t~Oll' II!:LD 'f -U
PROPERTY LOCATION -INCLUDE POST OFFICE
tlLDEQ. enOVi SU~DIVIOION SOUTH 2~D OTGuEr TO HAqOoa
SP;HtlO~IEL"
EOG6 11A!:CO~ D-Hllt:
PROPERTY LEGAL DESCRIPTION - METES BOUNDS ..
5TH ADDITIQ~ fIL9~RT GnovE Lor ~1
lJLCClt 3
TWP
18
RANGE
3
SECTION
11
TAX LOT NO
CODE
CENSUS TRACT '7 '8~
01 d
""
APPL
NAME
&
MAILING
ADDRESS
FOR MOBILE HOME PERMITS ONLY
No of Bedrooms
8~UM rLevCHal'l
EXISTING STRUCTURES ON PROPERTY
NONE
LEGAL ACCESS TO PROPERTY
HA"lOQ:l O;llvr
PROPERTY SIZE - FT
,
SA~C
WIDTH
DEPTH
AREA
STRUCTURES TO BE BUILT THIS PERMIT
Connect to EXisting Sewage System D
TYPE CONSTRUCTION SQ FT :::t BORMS
New System D
VALUATION
P~~IY Tn P~RU MC01L~ HO~E
2
PC'DrllY TO I tIDTllf L SE\1AOI1 Ol!1P03AL SYSTE::lIJ
SEW AGE DISPOSAL
PUBLIC 0
BUILDING
WASTE DISPOSAL
PLUMBING
PLAN REVIEW
PARK TRAILER
';:)3U:lCilt\rlCI!
TOTAL
.
FEES
PLUMBING INSTALLED BY
OWNER 0 OTHER NAME
WATER SUPPLY
SEPTIC TANK 0
OTHERD
'ie.oo
4.00
PUBLIC 0
o OTH ER
'\0.00
.04
t:Q.O!l
COUNTY
$
BUILDING & SANITA nON SPECIFICA nONS
MIN SEPTIC TANK CAPACITY
WITH DIST BOX GAL 750
DRAIN FIELD REQUIRED
lIN FT 150 TRENCH WIDTH FT
3DI!:PTH
OR SQ FT
3GO
STAY 100' ll'~O~ \1CLL ~lr~ ALL PAnTO OV SOE:
TYPE OF STRUCTURE OCCUPANCY lONE PUBLIC UTIL EASEMENT
t-~~ I
BLDG SETBACKS FT FROM CTR OF ROAD RIGHT OF WAY USE CLASSIFICATION
FRONT 45' SIDE INT 5' SIDE EXT REAR 5' .'
AUTHORIZED SIGNATURE - DATE DATE
Isl J. ' , &oss QV r. HAROIlUGI'l S.t.oo~ DIHHTAlllAfl 6/* 1'3
BLDG PERMIT ~ WHITE
OFFICE COpy - WHITE
COUNTY TAX - PINK
PLUMBING - CANARY
BUilDING - GREEN
SANITATION - GOLDENROD
IMPORTANT
Call 687-4065 to schedule all reqUired inspectIOns All construc-
tion shall comply with Uniform Budding Code, D E Q standards
for subsurface sewage dIsposal and county regulatIons covering
pl.Jmbmg All buildings requIre a certIficate of occupancy before
being occup,ed
(See Detads on Reverse Side)
\
.
FORM::= C55 13
(POST THIS PERMIT ON MAIN BLDG AT SITE)
LANE COUNTY. DEPT OF ENVIRONMENTAL MANAGEMENT
COURTHOUSE ANNEX, 135 EAST 6th, EUGENE OREGON 97401
"-
"
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.
SLAB FLOOR
PLUMBING GROUNDWORK
ApPROVED 17 01SAPPROVEO / / DATE INSPECTOR
REMARKS
....
GAS PIPING GROUNDWORK
ApPROVED 17 DISAPPROVED 17 DATE INSPECTOR
REMARKS
ROUGH PLUMB I NG
ApPROVED / / DISAPPROVED 17 DATE
INSPECTOR
REMARKS
ROUGH GAS PIPING
ApPROVED ~ 01 SAPPROVED ~ DATE
INSPECTOR
REMARK 5
FINAL PLUMBING
REMARKS
DISAPPROVED ~ DATE_9'-.J ,/-), INSP(CTO~~
(/ -
ApPROVED .!l(?:J
FINAL GAS PIPING
ApPROVED ~ DISAPPROVED I / DATE
INSPECTOR
REMARKS
CERTIFICATE OF OCCUPANCY
READY TO lSSUE 17 NOT READY TO ISSUE / / DATE
INSPECTOR
REMARKS
.
.. ,-
PROPOSl ,EWAGE OISPOSAL SYSTEM RECORO , " ~".
INSTALLER: Complete top part of form to sIgnature and submIt both copies with applicatian. . .
PERMIT NO. MH 125-75
INSTALLER'S NAME
PROPERTY AUURESS
SHOOK
TB'O SOP rf5J. fi.A N
No. LIvIng UnIts Bedrooms
Baths
HARBOR
Basement
Yes No
DRIVE
Water Supply
PubllcV Other-LIst
Septic Tank:
Ft. from well
Inside
Len9th
OWNER
NAME
DImensions.
WIdth
Steel D
Ft.
Diameter
Concrete ~ No. Compartments
Gal. Capacity
/()(j()
Depth
Tile DIsposal FIeld.
Distribution Box: Yes ~ No
Other DIstrIbution-Type
RRIJCr~FIF"Tr:HrR
~PPlh~~I~1 n npr~~l
Length of Lines-Ft. ] Trench
5020503,fo4. 5. 6. Width.l.
'lot Plan (see InstructIons):
Total Sq.
Ft.5oo
Feet from
WEll Foundation
Lot LIne
Front I 0 Side I 0
1Ft, Betwee.n IFlllerl IFilier Depth
LInes / f)-J I Tvpe I---?. Above Ti I e1-
Rear
IFi Iler Below
InJrl1e t, In.
MAILING
ADDRESS
7Rn \.J'~T M
/
e~ , , ,
~ \ Lo1 '17
'1"
IS if /
QS c:J
<:>
J;:J .so
D
;::r · lJvf><T'if
-
-< :r ctJR9 oX
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- .-.
,
Date ,JUt-V sr -"7,'7 SI9nature .,./f'4.-{~uN A.........,-:t,;;7'~ /
CERTIFICATE OF SATISFACTORY COMPLETION. I t1 hl//!
For Sanitarian Use Only: Date: / 1,17, 7~
In accordance with 1973 Oregon Laws Chapter 835, SectIon 214 thIs certIfIcate IS issued
as eVIdence of satisfactory completion of a subsurface sewage disposal system at the above
locat ion.
~Approved: System Installation conforms to current standards
r==J DIsapproved: Does not conform to current standards
Remarks'
STATE OF OREGON DEPARTMENT OF
f\
\J\~k
~arianls Signature
AN COUNTY
ENVIRONME AL QUALITY
C55-11
~ p~-~~ /"'~ PERMITtfI11-!-?2S75
. . NOTE NO PERMl /ILL BE ISSUED UNTIL THIS APPLI, <1O"S BEEN APPROVED ~
APPLICATION FOR
CONSTRUCTION c=J MOBILE HOME c:a- PLAN REVnW r=J CHMGE OF OCCUPANCY C=:J
~Aau- ;::It:-kAl'..e.. 1rfo tt'~~/f.Ji- ..;;f,R/J14J1dd 97-171'
CJ CONTRACTOR F~L~~~:: ~~7~; fk- :-~2:!1/l)
OS R1G II
ACCESS TO PROPERTY (Road Name)
Twp J f Range iJ Sectwn II Tax Lot
SubdiviS10n J-2k7~/p. ~tf Lot ';'1
/ld.,(2~ .:#~
dol)t;
Code
Census Tract
17-/<[-b
Block
3
Property Acreage
Width______Depth
Exist~ng Structures on Property
Property Location - Address/Dnections h/~eif a~ ~/.,#17YJ - ~~ 2 .d-
..PI- h ~ ~/L/~ hddU ~<?()(,.., b ffc,.,-h7)"-
t7v
Dr-r\~
/
'v B.elow
fo r Of f lC e Us e OnI yXXXXXXXXXXXXXXXXnXXXXX1.XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX~XlXXXXXXXXXXXXXXXXXXXXXXXXXXX1.
}./{ ++- -t~DS Sq Ft liB~~) / / / Valuation
/
/
SEWAGE DISPOSAL
Site Inspection #
WATER SUPPLY
Well -,
Spn.ng
EXlstlng Sewage Dlsposal System r=J
PubllC ~
Other CommunJ.ty [==:J
or NeC~System Required"-t:::::::!
o~unlty or Public System
-
Bldg
Waste Disp
Plumbing
Plan ReVlew
t:=)Q. -
l/. --
i~~~NrG1ib ~er [==:J
PLUMBI ( F
It of Flxtures
Jf
4-
~
<.-
FEES
Sewage
Connection
~
Water
Connectl.on
<..
Mobile Home
1% Surcharge
& ---;-
,nl/
TOTAL
/
~'/Oy
f -
pANS FU/ED
~S c:=J
Sl.gnature of
Fee Recel.ved By
FACILITY PERMIT
Min Septic Tank Capacity ~/~
Drainfield Requl.red - Ll.neal Feet
J <;:D
~c:=J NO
~~---1
Date -I.. -1/- 75
Maxl.mum Depth ~
Type of Constructl.on
/'itt:
Group
/
Fire Zone
Use Classl.ficatl.on
B1dg Setbacks - from Center of Road Right of Way
A,-{ ~,
Front ~ Side Int;;::) Sl.':~ :.::;..~~..~.....
Rear
r--.:c,_
~
Zone
eA--M \~
PI1NNJ;ll!i,-
~ e'lnh<
r ..
DATE
~TION
DEQk~~N-;
/ I DAtE. ___ j ,AUILDIN9! ///. DATE
(4/23111 /f/Y.JO-UM,0f h ~~ 6--75
I ,.{ . I
ENVIRONMENTAuVMANAGEMENT
C55 12
LANE COUNTY
OF