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HomeMy WebLinkAboutPermit Septic Tank 1975-4-10 ~y~ e~~:. I 'I~" '. V ::~R~~~:~~ER C RAWES . SAMF. LANE CC'" 'NTY BUilDING ....J rfll-J { 5. 7- 7~ BUILDING PERMIT OR MOBlr 'OME USE PERMIT MH rnx PERMIT NO. MH 11]--7<; MAILING ADDRESS PHONE 933 NORTH A STREET SPR I tlGF' t ELD OREGON 747-<;110 MAILING ADDRESS PHONE PROPERTY LOCATION - INCLUDE POST OFFICE .*' SOUTHERN EXTREMITY OF' rtL6ERT GROVE 2074 HARBOR DRIVE PROPERTY LEGAL DESCRIPTION - METES, BOUNDS rlL6ERT GROVE 5TH ADDITION lOT' 48. BLOCK, 18 , SECTION TAX LOT NO. CODE 11."z,,,.< # .3-..$.00 EXISTING STRUCTURES ON PROPERTY CENSUS TRACT TWP RANGE APPL. NAME & LAURENCE C. RAYNES Ml'u..r LEGAL ACCESS TO PROPERTY , . 2074 HARBOR' .(tft~ PROPERTY SIZE - FT. q" NORTH A STREET MAILING ADDRESS SPRINGF'lELD OREGON FOR MOBilE HOME PERMITS ONLY No. of Bedrooms WIDTH DEPTH AREA , Connect to Existing Sewage System D TYPE CONSTRU~T]ON SQ. FT. :# BDRMS 2 New System D VALUATION STRUCTURES TO BE BUILT THIS,PERMIT PACIK MOBILE HOME INSTALL'StWAGE DISPOSAL SYSTEM. SEWAGE DISPOSAL PUBLIC OPR lOR SEPTIC TANK 0 BUILDING ~ WASTE DISPOSAL PLUMBING PLAN REVIEW PARK TRAILER PLUMBING INSTAllED BY OTHERO FEES OWNER 0 OTHER: NAME WATER SUPPLY c;o . 00 .4.00 PUBLIC 0 o OTHER TOTAL $ ":l0.00 - .04 84.04 COUNTY BUILDING & SANITATION SPECIFICATIONS DRAIN FIELD REQUIRED MIN. SEPTIC TANK CAPACITY WITH 0151. BOX: GAl. 750 UN. FT 150 TRENCH WIDTH FT. 3 DE PTOR SQ. FT. 300 /'. TYPE OF STRUCTURE OCCUPANCY ZONE PUBLIC .UTll. EASEMENT MH I BLDG. SETBA<;:KS__ FT. FROM OR. OF ROAD RIGHT OF WAY USE ClASSIFICATION FRONT <;0' REAR '>' SIDE INT. 1:)1 SIDE EXT. AUTHORIZED SIGNATURE - DATE /S/ J. E. Boss. BY C.HARBAUGH JOHN SHOOK/SANITARIAN DATE 4/1017<; 01 M BLDG. PERMIT - WHITE OFFICE COPY - WHITE COUNTY TAX - PINK PLUMBING - CANARY BUlLDING - GREEN SANITATION '- GOLDENROD Call 687~4065 to schedule all required inspections. "All construc- tion sholl comply with Uniform Buildirg Code, D.E.Q. standards IMPORTANT: for subsurface sewage disposal and county regulations covering plumbing. All buildings require a certificate of occupancy before being .occupied. . (See Details on Reverse Side) F,ORM :;= C55 -13 (POST THIS PERMIT ON MAIN BLDG. AT SITE) LANE COUNTY, DEPT. OF ENVIRONMENTAL MANAGEMENT COURTHOUSE ANNEX, 135 EAST 6th, EUGENE, OREGON 97401 '. :;?:fr~-';;WE~.:, ~~.~~-'~;.,,,\:;,=.~>::\-.-;;::~;~.;J'~~~~~:~:~':. :~: ...: ':::'~~'.':;'C "';~;":~::-;f~;:"'~: ,. .,-,,;~ ',~. LA~.~':iJ.<:~: :&':,:-~0;~~~~ .:-'_:::~.--..., I .. .' -. - . ...... '," -., -'-- . . ::0i5"7 If :. /f:4KY5 o;Z D/2, I' . : . ..- .~ .. I. ." . . '--... :.':'; .... ~ .,' '.::".:;::::: ~;.:::...::.:o:.j~._.,-_ , .1 .' j "; , I i I I I .. I ,:/ ~!, ~ J' ,. .../ ""-/."7'-- '. . .', .} /1i I J.' "'-.' /' I ~ / f-....~! I / I~/Ol -: ;....; / '''--...; <--10 ~ 'f-/o,j'" ! 'V. I ~ r; .\1'.' i '/ . / ~- / . . "<- p'-J . / : ; Ii"., J " d"'.- " .,.:.,; .' .~-..:'- . ,,- . / ~ . /l_....... '-~. . .I{' I. . . 'JO . ~.I-"J. . ...~. : -8,<:.:."" Ji ' /! ...... ;., ~ ... '--': i I .. ..:...:...~_) '. . '. .,~. ''7 _:~,<,.,.:,., ..:,. -'____..i j' ~.. ,.,,<.,.," C(?:~Z .t" " ...:,\:~,<.: I!</ .:',,\\\: ~~l. / . I' . ,..-".--... ..)'. I ) 1.'.0,', . . ", ,: .~ ;. :_ i,. i. . . ,-, ' ~;:-... f .; I f ./ / 1 .,'" :R_ECEIVED By. _._ ._....L..___.. .' .C... ., ,. ....j.. i APRO 3 1975 I". -__. . bAN'~G6UNfy . ~NV'JWI\iM~t4tAb MGMT.,. jv, Hi!:3 7-7 ~ 0......-..-,,:.. , ! , "i . <~ . . -.:. i..: I. ..- , i !'. .~.. .', - ':........ . :;....~:.; . ........., , " , ,"-------- .\ ~....., ..\ ....... ._,~\ .----- .'...... ~........-. ~~\.-~~-.. .............,~ 'j , ,~._.. -"'---'~--7":'-. ) 1 , , I . -....,. -' -. ... -_..~.,..._,,-~~..,.. _.-:! -. ; .:",'" .....~ -- . I ..' . i.,.., 'T~~~~; . i; :.. . ...._~ j.-- .....,,~.. ",._._.__.n_ ____..t.~ ",..-:2, --.. .....'..,...{. -":'" i -.......... "'. ,\. .\ :1 .; i ! " '. f. . i \.! f \, i ,......\ J ,': "',1. ! / , .1 , ~.J'>-.. ! j. I ) , / .. "'. -... .;- . "---J'I/\ " .'. \ \ , , \ \;- \. .:, - -. . i I I I. ., i , I ! .! ~.'.;,;. . ~~~<<-:~ '.' 9' . .1_'.:' /','. 'N........ .. . . . . ' .:." , .? -,.,,,?:~ ,:'.. ... '- , ---- -. ~---- - . --.- ',. < ~,' . ,-' .j .~~ ~~""'.-,L I' -.. -- ,." .' , , .i ,.:;., . '. . ._.~. j .i , - .:.._---- -~'~1 .' -.;~" .,'/ I .' : . 1 -.' ~. ::)' .'?: .,' ,': ........ ~i_ _ .,.!'d.;~',:~;-:t~~: .J. ',.:". .. .~ .-.. ,. -, - . ....':.."..,-- 7, <",~, ,. ,.. "J' .-.~. '., ,~ ;,"'~).:: .'~ r ')", . .,~ i. , , I , , i ! i I i i -I I. I i I I I I , I , I . j ! , i I i i ! I I ! . i " 1"'-_ J .--- ., , ., : : i I , .J.._ ) , , \ ) I ! I ) -- ,'..----. .!J i i. , ! '( \-~..c 1J . T_ '<:6 'R 6~ S II TAX LOT. ~\. . .1" SUBDIVISION: NO. /; ..-:!'/3,?-7S-: LOT: BLOCK: . ~ ' APPliCANT' fu\!M~ -DATE BUILDING' SITE EVALUATION / , ( ) ( ) BUILDING PERMIT APPliCATION SITE 'I NS.PECTI ON 1. 2, 3, 4,. 5.. -.\ Not ,App l.i'cab 1 e Zon i ng Ord i nance Comp 1 i ance: Zonelfhtl-Mkl ) .Subdivision Ordinance Coop 1 iance . ( ) Requ i red Access . ( ) Building Site (Area, W.idth, 'Frontage) () Other (see comments) ( ) PLANNING DIVISION COMMENTS: No . Yes T).~6, ( ) (v) C) (t::-. ( ) ('7 ' ( ) ( ) CK'D BY:~ Setbacks from ell Front . Side Exterior Setbacks from interior Side Rear 1 j.nes: s-- c; 7' -;J'-7.s- of road: ~. - BUILDING INSPECTION DIVISION PLANNING DIVISION ACTION PENDING: YESl ) NDl ) APPLlCATION/t . Not Appl icable ( ) (() ( )' () 7, Plans Submitted 8, Soil Stability (footings) 9, Flood Plain . 10, Other (see comments) \ COMMENTS: ( "' WATER POLUTION CONTROL Not Appl icable () ( ) II,. Meets Department.of Quality Standards,. 12, Other (see comments) Environmental COMMENTS :' ./ , No Y~ t1 .,/ . T).~/-. ( ) () - ( ) ( ). ( ) ( ) . . /d/}/~ - CK'D BY,:{/.//Jt ..t./-r-'J& , . A!E No Yes T)N - , ( ) ( ) : . . , CK'D .BY: ~,\~ L/hh~ r \. DATE . \ " " TO APPLI CANT: , {o~ Building I ~ite Inspection: ;J?Q Can be approved. ..~ () Cannot be approved. at this time. as indicated on iKem.NO, above. )L~~~ jC) Questions and further information on items I through 6 conta.ct the LANE- "1~ ~~ COUNTY PLANNING DIVISION, Questions and furthe~ information on items 7 , through 12 contact the LANE COUNTY BUILDING AND SANITATION DIVISION. /. ( ) Will be held in this office unfil you can resolve the problems indicated. ( ) Is- be ing returned; (. ) Your bui.1dinq permit apJ>1 ication fee is be'inS! returned under seRar~te cove,!. _ "EPARTMENT OF ENV I RONMENTAL MANAGEMENT 135 Sixt~ Avenue East Eugene Or~gon 97401 , PHONE: 687-4065 . " LANE COUNTY PLANNING 91VISlpN PHONE: 687-4186 C55-28 -I ".-~ . . LANE cr. '''HY BUilDING. L1 IOME USE PERMIT PERMIT NO. ~ BUILDING PERMIT OR MOBIL M H [[)l( MAILING ADDRESS 9~~ ~~~1" A STREeT MAILING ADDRESS , PROPERTY OWNER LA~cr~~e C ~v~eo CONTRACTOR SAt::! PROPERTY LOCATION - INCLUDE POST OffICE S~ann t~TnE~ITY 0' rILO~RT G>1Cve 2014 H~oon OaIV~ PROPERTY LEGAL DESCRIPTION - METES, BOUNDS !'.;p.nlf<t\'.....u'J r'~OuBT ~1ova 5TH AOOITIOh LOT W Gt.oat ~ TWP RANGE CENSUS TRACT SECTION TAX LOT NO. CODE 18 1 11 APPl. NAME & EXISTING STRUCTURES ON PROPERTY LAURENCE C. RAYN20 1\,""'..... LEGAL ACCESS TO PROPERTY 207~ HAoacn ~.~ PROPERTY SIZE - fT. 9~~ N~T" A STn~~T MAILING ADDRESS SPell ~a' I GLD OorrOON FOR MOBilE HOME PERMITS ONLY No. of Bedrooms STRUCTURES TO BE BUILT THIS PERMIT WIDTH DEPTH )Jtl (.j ,1. ~. \. .' ~~ 111.. 7'~ PHONE"-' 1'k>""DU 7/.7.<;111) PHONE' - " AREA PMl~ ~OtLa Moog Connect to Existing Sewage System 0 TYPE CONSTRUCTION SQ. FT. :;; BDRMS 2 InsTALL S~AGE DIOPOSAL SY9T~ SEWAGE DISPOSAL PIllon PUBLIC D SEPTIC TANK D BUILDING $ WASTE DISPOSAL PLUMBING PLAN REVIEW PARK TRAILER OTHERD PLUMBING INSTALLED BY OWNER D OTHER: NAME WATER SUPPLY FEES c:;o .00 .lJ.OO PUBLIC D o OTHER m.M - .00 Bb.ch COUNTY BUilDING & SANITATION SPECIFICATIONS DRAIN FJELD REQUIRED TOTAL ; MIN. SEPTIC TANK CAPACITY WITH DIST. BOX: GAl. 750 L1N. fT IIJO TRENCH WIDTH FT , OlCPTOR SQ. FT. TYPE OF STRUCTURE OCCUPANCY ZONE PUBLIC UTll. EASEMENT t-Ol I BLDG. SETBACKS _ FT. FROM CTR. OF ROAD RIGHT OF WAY USE ClASSIFICATION FRONT 'W' REAR "i' SIDE INT. qt SIDE EXT. AUTHORIZED SIGNATURE - DATE I~I J. E. eooo ov c. HAQaAU~ JC'<lCJ 9HOC:t!t'1lt.l1't/lOI^,' BLDG. PERMIT - WHITE OFFICE COPY - WHITE COUNTY TAX - PINK PLUMBING - CANARY BUILDING - GREEN SANITATION - GOLDENROD New System D VALUATION ~oo DATE lJhnlm -. .-t' "'.'" t"l. 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 covering plumbing. All buildings require a certificate of occupa!1cy before being occupied. (S~e Details on Reverse Side) -. FORM = C55-13 (POST THIS PERMIT ON MAIN BLDG. AT SITE) <ANE COUNTY, DEPT. OF ENVIRONMENTAL MANAGEMENT COURTHOUSE ANNEX, 135 EAST 6th, EUGENE, OREGON 97401 \, SLAB FLOOR PLUMBING GROUNDWORK ApPROVED ;---y DISAPPROVED ~ DATE REMARK 5 GAS PIPING GROUNDWORK ApPROVED t / DISAPPROV[O ;---y DATE REMARKS ROUGH PLUMB.lNG. 'ApPROVED ~ DISAPPROVED ;---y DATE REMARKS ROUGH GAS PIP lNG' ApPROVED ~. DISAPPROVED ~ DATE REMARKS INSPECTOR INSPECTOR INSPECTOR INSPECTOR FINAL PLUMBING ApPROVEO !KJ DISAPPROVEO ~ DATE~-;;J +---J5' INSPECTOR ~ y/' REMARKS FINAL GAS PIPING ApPROVED / / DISAPPROVED / / DATE REMARK 5 .CERTIFICATE OF OCCUPANCY I. READY TO ISSUE ~ NOT READY TO ISSUE ;---y DATE REMARKS ~ INSPECTOR INSPECTOR ..... . . LANE CI"".INTY BUILDIN<L..'r ., .\., . . .,.\. BUILDING PERMIT .OR MH [JiJ:l: MAILING ADDRESS MOBW~IOME \"../ USE PERMIT PERMIT NO. It.'~"'. . ....'" . - PROPERTY OWNER \';W-.fb;.(".E C ttlTBt.t1B CONTRACTOR ::JA~.:l PROPERTY LOCATION - INCLUDE POST OFFICE '(.OH;~tl~" Eum:nan er E'11.6l:i:\'f PROPERTY LEGAL DESCRIPTION - METES, BOUNDS r 't .'t1i'1 G~~O'''/;l ')T;I JlDtltTtr;m 91~ :~tmTfl MAILING ADDRESS . . ... STl'ICrr'l' ~"/!]'Unftl"L" ldH t ';1.,.... ";...1 'PHONE'''' Ost:rot'tu 1t. ....:.-'r.';1 i'l PHONE' , . -' ~ " ,. GHQ1!<'t ?N4 H"'~Gr.i!l naA\;~ I lG't ~tJ a..OIl.: ~ TWP RANGE SECTION i.~ 3 J' .. TAX LOT NO. .. ) CODE ,/ (: EXISTING STRUCTURES ON PROPERTY CENSUS TRACT APPL NAME & !.Ar"c:,z:t;CIt C. [?lItYN<:8 8,,,,,"u... LEGAL ACCESS TO PROPERTY 2074 II!IItSOR ~ PROPERTY SI~E - FT. '.H"l :to'i11 II nl'Rf'U MAILING ADDRESS ~DttHtG7urt..O O$iZ'cr.;~:. 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. :;; BDRMS New System 0 VALUATION t~::::~~ teo~ft,e ,:~ 2 Ct'3ftlV<. $C'iIl'A<Ot I;H~plltl;fll.. S'1SUlil SEWAGE DISPOSAL F~.tI:[1' PUBLIC 0 ,. ~. SEPTIC TANK 0 BUILDING, $ WASTE DI,SPOSAL .PtUMBING PLAN REVIEW PARK TRAILER FEES PLUMBI~G INSTALLED BY OWNER 0 OTHER: NAME WATER SUPPLY OTHERD ":.0.00 ~.OO PUBLIC 0 D OTHER TOTAL m.oo .O~ t4.oll COUNTY BUILDING & SANITATION SPECIFICATIONS $ MIN. SEPTIC TANK CAPACITY WITH DISL BOX, GAl. DRAIN FIELD REQUIRED 'f50 L1N. FT. '50 TRENCH WIDTH FT. 1 D!i:ltl'OR SQ. FT. ~oo , , ., ~C\'-~.I:.~~ /~I.J\,.i~ ",,,-,\--\ \,\ \ TYPE OF. STRUCTURE ::1 OCCUPANCY ZONE PUBLIC UTIL. EASEMENT 3 BLDG. SETBACKS _ FT. FROM CTR. OF ROAD RIGHT OF WAY FRONT ~fl. 'SIDE INT. 51 SIDE EXT. AUTHORIZED SIGNATURE - DATE /J/ .'1. C. 6O~-ll- at c. liMWMH'.l. USE ClASSIFICATION REAR ").. JOtlN lJf!\DOll/lII\H I-tAIUAt.l DATE ,. hol1<;. c>, " 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 UniforfT! BuilsJing Code, D.E.Q. standards for subsurface sewage disposcil.c;riCi;'Jclouhty regulations 'o~ering plumbing. ,All buildings require a certificate of.o'ccupancy before being occupied. ~ . ..... (See Details on Reverse. Side) IMPORTANT: FpRM :::; C55 -13 ./ / (POST THIS PERMIT ON MAIN BLDG, AT SITE) LANE COUNTY, DEPT; OF ENVIRONM.ENTAL MANAGEMENT . COURTHOUSE ANNEX, 135 EAST 6th, EUGENE, OREGON 97401 " . ". , \, ~_. .......-.-, ! , , :---::: .. ~ . SITE I NSPECTI ON ApPROVED.C1 DISAPPROVED I / DATE INSPECTOR REMARKS FOUNDATION INSPECTION ApPROVED I I DISAPPROVED L-/ DATE INSPECTOR REMARKS FRAMING INSPECTION ApPROVED ;. /- DISAPPROVED II DATE INSPECTOR REMARKS LATH OR SHEETROCK INSPECTION APPROVED~! DISAPPROVED ~ DATE INSPECTOR REMARKS FINAL INSPECTION APPROVED' / / REMARK 5 ;1.14/ DISAPPROVED II DATE ,,';, fAJuJ~ ".")."~7r.lj ~ , INSPECTOR CERTIFICATE OF OCCUPANCY READY-TO ISSUE / / NOT READY TO ISSUE II DATE INSPECTOR REMA.RKS I1HmH~ 207"/ %~,1)...w , .' /rf rJ}:J - J~cL~ !NSTALLER: h:., .' l' '. . _... '. PROP()S SEWAGEDISPOSA( SYSTEM. RECORD. ..." . . .Comlll,ete.top.' part of' f'or:m to .sig,!ature and .submi.t'.both.cop,eswith application. , , . PERMIT NO. . MHl'n-7'i INSTALLER'S. NAME,... ~ p,ROPERTY. ADDRESS.. ._ .: l/2~f61LJ;,v ~~f~.:;z J .',.2<)74 r;IARBOR ,.', No,. Living Units BedroomS'. Baths Basement. Water Supply. .l "'- .'~ .. . .1 .Yes. No 'x Pub lic){ .Oth'er-L i st .. Septic Tank: ., Ft. from well". ... St.~..._~l 0::'.. Concrete 1)(1 No. COmpartments ' Gal;Cap~ci ty: . . ~ . -'. J~ao .4A--/ .lnside.Dimensions; F.t. - ,Tile.Disposal Field.:. -" .. LengthWfdth - Diameter_..D'epth :Di'stri'bution Box: . Yes'-.. 'No OWNER. Other Distribution-Type -NAME. .1 'A; 1';~~lr& (' :"OA v~,~ e " ,'_ JS . b3~ N~~TH A STREET.. '-. :~~l. ~ .. .SPR I NGF:' ELO OREGON Length ,of Li'n.~s-Ft, :lT~e,~chl. I, 2..3. 4.5. 6.. Width., 'lot Plan lsee -Instructions):' Feet from ' WEll ~t7c~~p7_ Foundation. ~~~n~ine II) I. '-Side;- {-:).. {: Rear /60 I 1Ft.. Betlj.een, .IFi 11'1ifjlfi ller Dept~/(IFIller~elow LInes' /ty Tvpel?'2JAbove T-i Ie G:; inlTi Ie I!.. in. . '. '.- . , /Zbcb/ '. I-lA.lL ING -ADDRESS Total. Sq. !'t. " ~ " I L /V\I F- . \...' , ~.,. ."", .':'p/f .; ~ IF ii. T <,/ . A-O ,: 7"l:'. ,4 , ':;L'/ .~.:-;:-- [,1 Ne ,. J. . -j(. . I ," ~.. L.il/e. .:z.# . j.. t ". ~ " i'- .#-'/V ' . .....,.:0...".; .... 70/ :1 . .( ~-J.l_, '\'11 - .., . . I- J /,-1 NE -# 3 ij{) '-t. r:- ..1. \\\ l \; ., 1J It \, Ir . \V ~ J ,- " .~ ~, '. .., - ..'f/: .DljTI2/8vT/D 60'1- .. \. \-c:. 'Ff.?,~At;l~ I .' '--', f\ld . At~IUj~ Date. .' - .. ," . .. S 19nature . . , ... ." . " CERTIFICATE OF .SATISFACTORY COMPLET.ION . ~ . , - .. ~ . For Sanitarian ~se'Only: . . I n accordance w.ith 1973 Oregon Laws .Chapter 835vSect I. on 214 th is. cert if i cate .as evidence .01' sa"dsfado~y completion of a subsur.face ..sewage disposal system location.. .-- :.-:. . &t.Appr.oved:' System I~stallatlon conforms to. current standards t::i Disapproved; ,Does not conform to current standards '. Remarks: - 'c..' '. . ,.... . . .RE-CEIVED .. . ~ -,,':~ ....... -. .., .. M AY 2~,'19_7.~. ., ., . .. I . . fat!' ;', tA~E COUNTY . " . ~VllWNMtNTAL., MGMT. ". ,'. ~l' Z .... _L 01 '\ 1 S ~. ~. /. ~~t~: 8127 j7-v IS Iss~l". .. at the above ,. JI\l\' .; , . ~~s' 'signature . . .L COUNTY -, ENVIRONMENTAL QUA~ITY "._- .C55-U. - ~.' Jj.,'. '." ........ .,.". ,-." ~ . . . STA!E ..OF OREGON DEPARTMENT OF ."" ,,; . -~ .. .PERMIT 1F1!j/l~/,j ?-J.) BEEN. APPROVED ~ -NOTE: NO PERMI' 'ILL BE ISSUED UNTIL THIS APPLI, rON HAS. APPLICATIONFOR:~ CONSTRUCTION .c====J. MOBILE HOME [)tJ 'pLAN REVIEW c=:J ClIANG~ OF OCCUPANCY 0 . . ~ .~ - - ' .. . . ~ OWNER~!<lI'f"f..MI/Nj.:C' . qq~ N. J~.~it-r- . '. . Name. '.,'. Address,. . .....- . 'J..:. .' . c=J CONTRACTOR. ""-" .' ~p I~PIr;L1)' ' I City 'q7LJ./7 Zip - i7tL7- 5;:/ I [) fhoue .,#IIIA - Name ~". , .Address City ,Zip.:, Phone 0.$. REG, II -- Twp. /~ Range-O'1, ..~ect~on j I SUbdi:iSion ~l' ~EIl\ G-tr<~ STIt-~Lot t+ f ACC~SS TO PROPERTY (Road Nam~) ~()rz4. 8ft/< M/2 Existing Structures on pro'perty:.. -pJOME' Tax Lot Gode Censu~ Tr'act 3r..:-tt!JJO , I . Width~DePth~ " Blci~k-.3 Property Acreage ~;;<d)4 J-I,aP2ol? .DiiIE DP I Vi"' ... . / 5,()( )17it:r'? ~l:;- )( Tlf'efYJ I Tf' v;P ('It KEPI r.:rL ., ,. ;/ . OnI yxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx]{}{JQ(ri:xxxxxxxxxxxxxxxxxxxxxx Sq. Ft. ilBedrooms/- Valuation .:1- .- / / .' . Property Locat;op. - Address/Directions: Below for_Office Use ~~~~.~. , ,~ ..-:' ,j,;; .. ~ -.. ~ ~.-4iV$ SEWAGE DISPOSAL; . JO.A~ Sit"e .Inspedtion fl. 'T." _'-.,.-V WATER SUPPLY.: Well ;:J rJ, () () ,eif/ ., ! Owner ~ O=:J . r / :.. '"0 .New System Requued C:=J fre- ' -/~ ., ~ .Community or Public System ~ .,. .Spri~g" E~i;ti~g Sewage Disp~sal System. ~ Public' ~.: Communi"ty,. ~ Ot.her c : .FEES: PLUMBING: . Installed 'by Name Bldg__. Waste Disp. Plumb'i!lg 'Plan Review Mobile Home 1% ,Surchar.ge 5l),oo 1/: 0. 0 PLUMBING FEES: Sewage '-- . Connec tion . d' t.. ,. Water . Connection .::2 , TQTAL fi-l.f. () 'i" .. .-'0 CASH' .'I:~.' PLANS FURNISHED FACILITY PERMIT .tfJbo'r . .~' ~YES c=J NO ~ Y~S NO_ Signature of APp~icant~/"''''Lf/--:'' '~!:f-~v FeeReceivedBy:Q.p~ . Date: k-? "/,\- 'I' 4<;' r " ~in. Septic T.ank Capacity~ ~ L 1DGa'infield 'Required - Lineal Feet i 5L:::> Maximum D~Pth' -'2, :. Type of Construction .IV! J.{ . G,~up i Ffre Zo"ne ,Use' Classificat~on" . Bldg.Se~backs - from Center. of Ro~d Right of Way: Fronf;:/-W'f;:.~(J) Side Int. :~.. Side Exterior " " . Rear' s-. .Zone' iT .(/>(,.4.-/1.1 /4. <;:55-1.2 :' ..4/;~~n;~ .., ._ ~~:Lj/717~j)4~"~ ~_D?~~j_ LANE. COUNTY ~~ENT OF ENVIRONMENTI' MANAGEMENI PIA~