HomeMy WebLinkAboutPermit Septic Tank 1975-8-15
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PROPERTY OWNER
BUILDING
MH"oo
MAILING ADDRESS
"
PERMIT OR MOBILE HOME USE PERMIT
PERMIT NO,
MH419-75
PHONE
. (,-~',... ;,
, : ~.
Hubt>.rt J. KalthJev'
CONTRACTOR
MAILING ADDRESS'
PHONE
Ted SonteJeen 5000 p'relrle .Junction Cltv. Orellon
PROPERTY LOCATION - INClUD~ ,P9S! OFfiCE
Harbor Dr ive . 201'J' Harbor Drlve-
. PROPERTY LEGAL DESCRIPTION - METES; BOUNDS '~.
688-9750
'.
;',t.,:
Fifth add to Filbert Grove
L-20, B...:6
TWP
RANGE
SECTION
TAX LOT NO.
CODE
CENSUS TRACT
18
03
//,.;1.:< ~
~~
APPL
NAME
EXISTlNG STRUCTURE~ ON PROPERTY
none
LEGAL ACCESS TO PROPERTY
&
MAILING
ADDRESS
fOR MOBILE HOME' PERMITS ONLY
No. of Bedrooms
~lRUCT.UR_ES ,TO ,BE BUILT THIS'PERMIT
Harbor' Or! ve
PROPERTY SIZE - FT.
WIDTH
DEPTH
AREA
Connect to Existing
TYPE CONSTRUCTION
Sewage Syii'em D i New System D
SQ. FT. :;:t BDRMS. VALUA"tION
,
(-2) \
-....,
,ln5t".!l S..nt,l,c, o I 5nn5i> 1 SVgtEm,
p~rk Mnailp. H~~p
SEWAGE DISPOSAL
PUBLIC 0 SEPTIC TANK
BUilDING
IW ASTE DISPOSAL
,PlUMBING
PLAN REVIEW
PARK TRAILER
pr lor
,8, OTHERD
.
FEES
PLUMBING INSTALLED BY
OWNER 0 OTHER: NAME
WATER SUPPLY
1nn nn.
IL nn
PUBLIC 0
o OTHER
rnrnmllni1-v
TOTAL
'2n nn
,'>
1.,1. ,,,
I
MIN. SEPTIC TANK CAPACITY
WITH DIST. BOX: GAL
COUNTY BUILDING & SANITATION SPECIFICATIONS
DRAIN FIELD REQUIRED
7"0
UN. FT
1"0
TRENCH WIDTH FT, 3" deDthOR SQ, FT,
300
TYPE OF STRUCTURE
OCCUPANCY
ZONE
PUBLIC UTIL. EASEMENT
tU' "
BLDG. SETBACKS __ FT. FROM CTR. OF ROAD RIGHT OF WAY
RA_MH
USE CLASSIFICATION
FRONT hE:
SIDE INT. 7. SIDE EXT.
AUTHORIZED SIGNATURE - DATE
REAR 7
DATE
.Ink" .C::~..."L-/C::'An tfoA...tAn
"..,
BLDG. PERMIT - WHITE
OFFICE COpy - WHITE
COUNTY TAX:- PINK
PLUMBING - CANARY
BUILDING - GREEN
SANITATION - GOLDENROD
.-
. .t: r:: _: Rnt:~ .hv r.hm..1A~. ~rh.-Q.ltnh A-: 1 1:-:- 74:. bp
Call 687,4065 to schedule all required inspections. All construc'
tian shall comply with Uniform Building Code, 'D.E.Q. standards
for subsurface sewage disposal and county regulations covering
plumbing. All buildings require a certificate of occupancy before
being occupied.
(See Details on Reverse Side)
IMPORTANT:
!~::~~:OR~.'::::.C55~:,\Jt...,~ ''-'~,:..,A',_,,;.~ ,'..'-.'
(POST THIS PERMIT ON MAIN BLDG. AT SITE)
LANE COUNTY, DEPT. OF~ENVIRONMENTAL MANAGEMENT
. ' COURTHOUSE ANNE}(, 13~' EAST ~th. EUGENE,. 6~EGON 97401
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~U I LD I N-G. S ITE EVALUAT ION '- '
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(~BUILDING PERMIT APPLICATION
() SITE INSPECTION
\ G If..J!..A- TJfj~ O~ SJ1-==2,.7TAX LOT ~
..J / 'J.-V'/ \ SUBD I 0"1 S I ON:
NO. nllf ./-/9-75;, LOT: BLOCK:,
APPL I CANT tp ; fh l-ev 1St> ok/fa 11\
DATE / ' I
PLANNING DIVISION Not
Appl icable
1. Zoning Ordinance Compliance: Zone ~~-~JV)
2; Subdivision Ordinance Compliance ( )
3. Required Access ( )
4. Building Site (Area, Width, Frontage) ( )
5. Other (see comments) ( )
COMMENTS:
No Yes
() (~6.
( ) ("'J_
( ) (1:- '
( ) (""",
( ) ( )
CK'D BY~T"1I:c:./h<
Setbacks from c/l' of 'road;
Front ~
strlo 6:xterisl'
Setbacks from
Side
Rear
interior lines:
., f "" e:
I' CU~ _
BUILDING INSPECTION DIVISION
PLANNING DIV.ISION ACTION PENDING: YESl } NOl } APPLICATION#
7. Plans Submitted
8. Soil Stab i I i ty (foot i ngs)
9. Flood Plain
10.' ,Other (see comments)
Not
Applicable
( )
~)
( )
)
COMMENTS:
WATER POLUTION CONTROL
Not
Appl icable
. ( )
( )
11. Meets Department of Env i ronment'a 1
Quality Standards.
12. Other (see comments)
COMMENTS:
r) '!!J3rA~
( ) ~F'
( ) ( ) /f)~ / j
( ) ( ) CK'D BY(/I~ fl-'0..-70'
f DATE
No ?)
() ,
( ) ( )
CK'D By:Q)l ?;J6/7~
OATE
TO APPLI CANT:
Your Building / Site Inspection:
!2 yf Can be approved. '
;1 () Cannot be approved at this time as indicated,on item NO. above.
.J'I~(ff( Questions and further information on items 1 through 6 contact the LANE-
~J COUNTY PLANNING DIVISION. Questions and further information on item5 7
through 12 contact the LANE COUNTY BUILDING AND SANITATION ,DIVISION.
( ) Will be held in this office until you can re50lve the problems indicated.
( ) Is being returned. '
( ) Your building permit aEplicil.!,\2-,,_Je~~einq.~~t..u.r::'l)ed un~ seoar;,te cover,
~EPARTMENT OF ENVIRONMENTAL MANAu~MtNT '
135 Sixth Avenue East Eugene Oregon 97401
PHONE: 687-4065
LANE COUNTY PLANNING DIVISION PHONE: 687-4186
C55-28
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8-18-7S ~ ""',,
Permit No,,'
MH 419"75
,CURB CUT'
','-
:.1
. '".
,PE,'R'M I T
IN THE BOARD OF COUNTY COMMISSIONERS: OF LANE COUN,TY
, .
,WHEREAS, the attache,l' application ,has been fully considered by,the, Board of County Com,
missioners of lane County, and, it is th,e opinion and judgment of the Board that the said application
should ,be granted, and that a permit. should be issued, now, therefore, it is hereby.
. - .'
. '
ORDER,ED, that a permit b~,'~nd ~s hereby ,issued to
Hu,bert J. Keithley
% Ted Sopteleal1
or constructing the
5000 Prairie Rd.
follo",,'i,'g f,:,cility:
, Junct i on City. Or.
for placing; building
Mobile Home.,
5th" Add. Fi t~ert Grove' L. 20, B'. 6
2011 ffiarbor 6rlve
upon, the right'of,way' of County RO,ad No: " ';' Mile Post ,
.- in strict conformity 'to the exhii=?its 9ttached hereto'/ and sul?iect tQ ,alLtermst conditionst agreements,
stipulations and provisions contained in the applic9tion and permit, ,the Rules,and RegulationsGov'
eming Facilities to bePermitt'ed upon, County 'Road Rights,of,Way; ,as set forth by the lane Man,
ual 50.190(2) any amendmerlts thereto, and 'any ot,h,er ,applicable regulations, law or ordinance.
"Special Provisions:,
,-
"
1. Driveway will be constructed in"accordance with the attached driveway approach specifica'
tions (Drawing M98,5'O).
2. Permittee will be re.sponsible for the immediate removal of all mud, dirt and debris from the
roadway and right' qf way caused by his operation, le9ving the roadway and area in a neat,
acceptable condition..' '.'" , , '
3.
Sidewalk5 will be constructed in accordance'with the .attached sidewalk
specifications and dr<iwi~g M98-49. The standard curb type shall be
Construcfed unle55 otherwise: sp'ecified'.
"
that
, '
- . - - . ~ .
This' permit is 'revocable at any time, and will be sirictly adhered to and no work other than
specifically mentio!,ed, Slboveis hereby authorized. '
,This permit shall,be'void un'less,the work herein ~ontem~lateishqll have been completed be,
..fore
AIIO lR
19~.
Expires
,19~.
Inspected and Approved "
Approved ,by' Board of County Commissioner5
By
m/f)/Udut
Date
By"
Director of Public- Works ~
WHITE - OFFICE FILE
GREEN - RESIDENT ENGINEER
PINK - PERMITTEE
. BLUE - ROAD 'SUPERVISOR .
"ORANGE - BUILDING &' SANITATION DEPT.
YEL~O.W - REAL "ESTATE'
,',
C98-79
.
:R
LANE COUNTY
BUILDING "J
~
PROPERTY OWNER
BUILDING PERMIT OR MOBILE HOME
MH [;J
MAILING ADDRESS
USE PERMIT
PERMIT NO,
PHONE
CONTRACTOR
MAILING ADDRESS
PHONE
PROPERTY LOCATION - INCLUDE POST OFFICE
PROPERTY LEGAL DESCRIPTION - METES, BOUNDS
TWP
RANGE
SECTION
TAX LOT NO
CODE
CENSUS TRACT
APPL.
NAME
&
MAILING
ADDRESS
FOR MOBILE HOME PERMITS ONLY
No. of Bedrooms
STRUCTURES TO BE BUILT THIS PERMIT
EXISTING STRUCTURES ON PROPERTY
LEGAL ACCESS TO PROPERTY
PROPERTY SIZE - FT.
WIDTH
DEPTH
AREA
Connect to Existing Sewage System 0
TYPE CONSTRUCTION SQ. FT. :: BDRMS
New System 0
VALUATION
.
FEES
PLUMBING INSTALLED BY
OWNER 0 OTHER: NAME
WATER SUPPLY
SEWAGE DISPOSAL
PUBLIC n
BUILDING
WASTE DISPOSAL
PLUMBING
PLAN REVIEW
PARK TRAILER
SEPTIC TANK 0
OTH"O
.PUBlIC 0
o OTHER
TOTAL
$
MIN. SEPTIC lANK CAPACITY
WITH DIS1. BOX: GAL.
COUNTY BUILDING & SANITATION SPECIFICATIONS
DRAIN FiElD REQUIRED
L1N. FT
TRENCH WIDTH FT.
OR SQ. FT.
TYPE OF STRUCTURE
OCCUPANCY
ZONE
PUBLIC UTll. EASEMENT
BLDG. SETBACKS FT. FROM CTR. OF ROAD RIGHT OF WAY
USE CLASSIFICATION
FRONT
SIDE INT. SIDE EXT.
AUTHORIZED SIGNATURE - DAlE
REAR
DATE
BLDG. PERMIT - WHITE
OFFICE COPY - WHJTE
COUNTY TAX - PINK
PLUMBING - CANARY
BUILDING - GREEN
SANITATION - GOLDENROD
Call 687-4065 to schedule all required inspections. All construe.
tion sholl 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 occupancy before
being occupied.
(See Details on Reverse Side)
(POST THIS PERMIT ON MAIN BLDG. AT SITE)
LANE COUNTY, DEPT. OF ENVIRONMENTAL MANAGEMENT
COURTHOUSE ANNEX, 135 EAST 6th, EUGENE, OREGON 97401
fORM = CS5-13
"
.,
SITE INSPECTION
ApPROVED C1
DISAPPROVED C1 DATE
INSPECTOR
REMARKS
FOUNDATION INSPECTION
ApPROVED L-I 015APPROVED / - / DATE
INSPECTOR
REMARKS
FRAMING INSPECTION
ApPROVEO /~ DISAPPROVED /7 DATE
INSPECTOR
REMARK 5
":,II!:i,.,
LATH OR,SHEETROCK INSPECTION
ApPROVED L-/ DISAPPROVED ~ DATE
INSPECTOR
REMARKS
FINAL INSPECTION
ApPROVED C1 DISAPPROVED C1 DATE
INSPECTOR
REMARK 5
CERTIFICATE OF OCCUPANCY
READY TO ISSUE /7 NOT READY TO ISSUE I I DATE
INSPECTOR
REMARKS
"
(r11f if! r- 75 j( 4Uc/f
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r LANE' 90tlNTY
.:. BUILDING n
BUILDING PERMIT OR
MH [j{]
MAILING ADDRESS
MOBILQ~ME
,:: {'l~ --: ' " ;. -~~ ; ,qr;,._:_ '~,..- .<1, ~.:-l' .o--~: '" -" _
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f'-' .. ..-
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USE PERMIT
PERMIT NO, e1Hblq..,<;
PHONE
PROPERfY"OWNER
l'luh,,,,..!,,.1. (ent thip."
CONTRACTOR
MAILING ADDRESS
PHONE'
Tad Soota't'lnll liOllO Pralrlo Junction City. OroClOn
PR9PERTY LOCATION - INCLUDE POST OFFICE
Harbor Or 1110 %011 ll('la-bar DrIve
PROpERTY lEG:A-l DESCRIPTION- METES, BOUNDS
688..9750
.".,
TWP
RANGE
SECTION
L-20 9-G
TAX LOT NO.
CODE
CENSUS TRACT
Fifth edd to ~t'bort Grove
18
03
,28
APPl.
'NAME
&
MAILING
EXISTING STRUCTURES ON PROPERTY
mmo
LEGAL ACCESS TO PROPERTY
Horbol" Dr IV<lI
PROPERTY SIZE -.FT,
ADDRESS
WIDTH
DEPTH
AREA
FOR MOBILE HOME PERMITS ONLY
No, of Bedrooms
STRUCTURES TO BE BUILT THIS PERMIT
Connect to Existing Sewage System 0
TYPE CONSTRUCTION SQ. FT. :t; BDRMS
New System D
VALUATION
Infltal' Seftt>le Dlnnoa~1 SvSf~~
m
PII"k Mati tin 'P.n.'TI'"
SEWAGE DISPOSAL
PUBLIC n SEPTIC TANK
BUILDING
WASTE DISPOSAL
PLUMBING
PLAN REVIEW
PARK TRAILER
prior
lGl~ OTHERD
.
FEES
PLUMBING INSTALLED BY
OWNER n OTHER: NAME
WATER SUPPLY
,;~"~
Inl\M
l.\l'tn
PUBLIC 0
o OTHER
"""""","'t"
,
':In nil
1')
<t I~b 1"J
COUNTY
BUILDING & SANITATION SPECIFICATIONS
,TOTAL
MIN. SEPTIC TANK CAPACITY ...__'
.;-'". .' ,
WITH DI5T. BOX: GAL. 7;0-
DRAIN FIELD 'REQUIRED
( .. --. \
UN, FT 150 TRENCH WIDTH FT, :3' dapthoR SQ, FT,
300
TYPE OF STRUCTURE
OCCUPANCY
ZONE.
PUBLIC UTll. EASEMENT
till I
BLDG. SETBACKS __ FT. FROM CTR. OF ROAD RIGHT OF WAY
M-I1H
'USE CLASSIFICATION
FRONT ~
SIDE INT. 7 SlOE EXT,
AUTHORIZED SIGNATURE - DATE
REAR 7
J~hn Shnfi~lnm"'tnrl~"
DATE
J.E. BoOB bv ChQrlotl tw"bOOKlt! G-1501S 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 sewo_ge disposal and county regulations covering 1
plumbing, All buildings require a certificate of occupancy before
being occupied,
(See Details on Reverse Side)
BLDG. PERMIT - WHITE
OFFICE COpy - WHITE
COUNTY TAX - PINK
PLUMBING - CANARY
BUILDING - GREEN
SANITATION - GOLDENROD
,-." . ,F.,?_R ~.~_<;:_S_5,~. .1}....._.... ..".,....,',,:'-;.!>~- '.
(POST THIS PERMIT ON MAIN BLDG. AT SITE)
LANE COUNTY, DEPT, OF ENVIRONMENTAL MANAGE,MENT
COUR~HOUSE ANNEX, 135 EAST 6th, EUGE~E, OREGON 9740~
",,,,"-',. ",'L~~..:,~~.,",;!.:'~:,~-,':"'" ,:,.,~~.".-; <>h'::. ..- ....'..; " ",_.~"
.o,.'k,,'~\_
SLAB FLOOR'
PLUMBING GROUNDWORK
, .'
ApPROVED / / DISAPPROVED ~ DATE
REMARKS
GAS PIPING GRoUNDWORK
ApPROVED ;---? DISAPPROVED ;---? DATE
REMARKS
ROUGH PLUMB I NG '
APPROVED.! / OISAPPROVED / / DATE
REMARKS
ROUGH GAS PIPING
ApPROVED .~. OISAPPRQVED .0 DATE
REMARKS
REMARKS
FINAL GAS PIPING
ApPROVED ~ DISAPPR~.vED 'j / DATE
REMARKS
CERTIFICATE OF OCCUPANCY
READY TO ISSUE:/ / NOT READY TO ISSUE ;- I 'DAfE
REMARKS
,.
\
\ NSPECTOR
INSPECTOR
INSPECTOR
INSPECTOR
',..
j
INSPECTOR
/
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INSPECTOR
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Permit No
I'~. M9--7!i
CURB CUT
d' . .
. Date .J,. iJ..:r.;
.
PERMIT
IN THE BOARD OF COUNTY COMMISSIONERS OF LANE COUNTY
WHEREAS, the attached application has been fully considered by the Board of County Com,
missioners of Lane County, and it is the opinion and judgment of the Boord that the said application
should be granted, and that a permit should be issued, now, therefore, it is hereby.
Hu bert J. Kalthley
ORDERED, that a permit be and is hereby issued to
'., Ted Supteleall I)OJ\3 Prall'lo ltd. . Jllnetloo <ll.
or constructing the following facility: tklbllCll 1i0CllQ
5th Add. Flttert Gl~ve L. 2G ~. 6
OJ'.
for placing, building
l!Otl tamOf' Drlv.
upon the right,of,way of County Road No. , Mile Post ,
in strict conformity to the exhibits attached hereto, and subject to all terms, conditions, agreements,
stipulations and provisions contained in the appl ication and permit, the Rules and Regulations Gov'
erning Facilities to be Permitted upon County Road Ri9hts,of,Way, as set forth by the Lane Man,
ual 50.190(2) any amendments thereto, and any other applicable regulations, law or ordinance.
Specia I Provisions:
1, Driveway will be constructed in accordance with the attached driveway approach specifica'
tions (Drawing M98,50).
I 2. Permittee will be responsible for the immediate removal of all mud, dirt and debris from the
roadway and right of way caused by his operation, leaving the roadway and area in a neat,
acceptable condition.
3l. Sid<iWAI~lII wi II 0;'; GOOlltru<:teO In accordanca whh tile aUKhed sld_lk
llfl~I~I~tIOl1S ~id r\l"Eil'tinj; M9H~49>. T~o I!IlanlJ!lr{J curb tYiI'* slutU be
Constructed Unl~$5 C)~h~""lsc S :lIdfl J,i.
.../i
{l" CV
J1(
that
This permit shall be void unless the work herein contemplated shall have been completed be,
fore
Aug. HI
70
,19_.
Expires
,19_.
Inspected and Approved
Approved by Boord of County Commissioners
By
Datp
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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I NSTALLE'R:
PROPOS l
Comp I ete,'top, part .of :,form
.iEWAGE 0 I SPOSAL SYSTEM ,RECORD '. ,
to signature and submi,t both copies,with,applicatioQ.'.
" , ' 'PERMIT NO. MH4,19~75' JS
INSTALLER'S l'!AME
Tf3.'tJ J 0 p: T-F3.J,..EA JJ'
No. Living Units Bedrooms ,~Baths
Septic Tank:
Ft. from we~l ,'~ ' 'S~eel' 0
Insice Dim~nsi.ons:" Ft.' ,
Length Width, \. 0 i ameter
OWNER T,ed Soptel ean/Ke i th ley
NAME
PROPERlY AUURESS
2011 Harbor Drive
8asement
, Yes , No
Water Supply
Publ ic '//' Other-,List,,'
:~o:ncr<"te'!i2r NO., 'Compartments
Tile Disposal Field:
Di5tribiJtJon 'Box: Yes 1/ No
Other Di str'i,biJti,on-Type
Ga I. Capac ity
/0 DO
Depth
Feet from
WEll
, "I Lot Li ne '
,Junction City, OrEigon', ",' Front"
Length of L i nes-Ft., ' l T~enc~ I Tota I Sq. ,I Ft. ',Between
1;t::;2:1~3. 4; ,5. 6. W,dthJ.! Ft..'?OO, Lines' to
'lot Plan {see'instructionsl:
.. >, ~Uo'? 0 .><( ,
i)I-,.~'( f/ I'l, IX J
,~llPP ,','\..
- ' ,
'HA-Y<.~ 0 An R Iv/:.
Si gnature ' {A' f!,!-"rl(Ar>'
, CERTIFICATE OF SATISFACTORY COMPLE'T10N
For SanJtaria~ U5e Only: , ,
, I n accordance wi th 1973 Oregon Laws Chapter 835. Sect i on 214 tti i s certi'f i cate'
'as evidence of satisfactory completion of a sybsurface ,sewage dispqsal system
'location.' , " , '
~ Approved: System, Insta'l,iation' conforms to, current standards
!:tJ 0 i sapproved: Does not "conform to ,current stand,ards '
Remarks: ' '
MAILING
ADORES S
5000,Prairei Road
'<:), " ' ,
',"", , ,
,.,~ ~'-;.;-n-bo~ /(/+:
"
10
/0
''\ '\
L~ ,~
J\.
,--
,/....
o
"\"..:
"
Date A I/,t; 7 -"'7.1;'
C55 -11
Foundation
10' Side! DRear / c)
IFil'ler/'IFiller Depth ,lFiller Below
Type/~ Above Tile;L inJrile (, in.
~. "~-' .
I "I.
, ,',,:(.' ,NO R-r H
l!J
~'
<>
't '
I.!., J-
~ \1
~
<::)
'{.
"o.-:J
,
.....0.
By RECEIVED
,,~:
AUG291975 '
, ' LANE C '
f.NVIRONMf.N~UNTY
, , ' AL MGMT.
'. .;.
.,
~.
Y",rYJ""'7;i{/".",,_~
-;
Date: <{ -I-r~r
is issued
at the above
'.
STATE OF, OREGON DEPARTMENT ,OF
,"A!V~ "
, , San9 t lr i an's S,i gnature
lANK) ;OUNTY , "
ENVIRONMENTAL QUALITY
r
~l
'.
)0 ~ ~. - .
NOTE: NO PERMIT ",LL BE ISSUED UNTIL ',THIS APPLIC
APPLICATION FOR:
.I1'JlitrT~/9-7 S
.ON HAS BEEN APPROVED ~
(.~
, CONS~RUCTION c::J, MOBILE 'HOME ~' PLAN REVIEW c::J CIIANGE OF OCCUPANCY
'flIIP~f{ TJd< D-ITHJ...e.y ,
OWNER EJ.../ ZA ,15' E-'1H K5-/ TH t.EY
;.;' Name Address City Zip
c:::::J
CJ
PhoI].e
~CTOR TEn SDfJif~1. &/riV 6u'(jofJJ{,4J~/f.
Name Address
JIJA/,.'rIONcrry (., R'J?-CJ-iso
City ZipQ1'N 8 Ph~ne
O.S. REG. II
Twp. J! ' Range O. ~ Section ;l t, Tax Lot 2 0
~vt.1'fn'..cIt. /iEk -r G}WIt'ELot 2 0 Block' 6
Code . Census Tract
Property.Acre<!ge Width--'-.--Depth
ACCESS TO PROPERTY (Road Name)
~roperty Location :. Address/D~Fec.tions:.
lVoNt:!'.
l..J.fr~B(}~ I)I1IVE.
cO /I I I k.!~rl<..A I--ck/LJ
tr.Lt ./
Exist-iug Structures on Property:
Below fo r Of f ice -Us: e - Onl V XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
.Jh, LJ;!?E! A ~ ,,\ Sq. Fe. i~Oms)" /Viiluation
>>)rJ A K _ 'rn ).....1- '"-' /'
./
/
/
SEWAGE DISPOSAL:' ,\
Site Inspection 1'~lI~
WATER SUPPLY:
Well
TOTAL
,2() , n ()
;/Vc::::::::)
r.o .
/.34~
CASH
/ c::::::::)
or New lem .Required
Conununity or Public System
/ '
1
Other c::J Name
I
Sewage ..--,'_
Conrfection' ~
/
i'
DWt~'""~ . I'~
tr" . YES c::J NO ES 0 NO
/ , ~A 9 u.J....9. '
Signature of AP"ff:A:!f~ ~~eQA~_
lee ReceiVed'BY~i'uiJ, Date: ""'}....~L::J .:::;
Drainfield Require/- Lineai.. Feet ./ ~~ _Maximum Depth ~
\ /
\ /-
'-.-/
CJ
Existing Sewage Disppsal System
Public
c::J
Spring'
O~her
Commul}it"y JLI' -- . Name: of
FEES:
Bidg.
PLUMBING:
Instal~ed ~y Owner
c::::::J
Was te Disp.
Plumbing
Plan Review
Mobile Home
1% Surcharge
/ frn.o1J
. l/.Lff7)
.
PLUMBING FEES:
ff' of Fixtures
Water
Connection
2
~K
Min. Septic Tank Capacity
'=r~
Type of Construction
/VI.Jf
"
"Group
f
Fire Zone
Use Classification
Bldg Setbacks - -from Center of ~(ad~ight of Way:
Front 4J:,,1 Side Int.7 f""a t:::; S~;,L
Rea;! ( p(j 60ne RA.-rvI l.l
PlANNING:
-d.r:r 11~1 \~
DATE:
-
'\\1tA~ON:
~A:~ENT
g/~'7K-*~d' g}~;~
OF ~NVIRONME;TAL ~NAGEMENT /
.9';
(55-12
'LANE, COUNTY
..