HomeMy WebLinkAboutPermit Building 1974-03-12--_\--l
R MOBITE x$IANE COUNTY ILDING PERMIT O
PERMTT TYPE - BU|LD|NG L MOBTLE HOME
SE APPLICATION
SC REG PERMTT #
OWNER MAILING ADDRESS
MAITI G
77d*o
PROPERTY TOCATION _ INCTUDE POST OFFICE
-1/5 O' " t-. /€4.
PRoPERTY TT{or rrrr*,rrrK
TOT_BTOCK_SUBDIV.
METES & BOUNDS
ATTACHED
YES
NO
TWP RANGEOJ SEC.TAX LOT CO-DE CENSUS TRACTJ/- zoo/z -L2. 4 { -r9*a /?-q a
APPLICANT
NAME
AND
MAILING
ADDRESS
DESCRIBE EXISTING STR RES ON PROPERTY IF A
TEGAL ACCESS TO PROPERTY _ ROAD NAME OR
AREA
FOR MOBILE HOME PERMIT
Number of Bedrooms
STRUCTURES TO BE BUITT THIS PERMIT
NLY2 Connecl to Existing Sewoge System or New mRe
TYPE CONSTRUCTION SQ.BEDROOMS VALUATION
R
a4de Z'
)vrz*
SEWAGE DISPOSAT PI-UMBI INSTAIIED BY
O ra*Pt?a
PUBTIC
BTDG.
WASTE DIS.
PLUMBING
PI.AN REVIEW
PARK TRTR.
SEPTIC TANK
-=ii, r-t,CASH !ER
--V a4>
34 *"
OTHER
FEES WATER SUPPI'Y
PUBTIC
PLUMBI FEES
-
FIXTURES
CHECK
OCCUPANCY
OWNER E OTHER NAME
PTANS FU
YES
SI
OR SQUARE FEET
REAR YARD
USE CI-ASSIFICATION
FACITITY PERMIT
DATE
PUBTIC UTII.. EASEMENT
OTHER YES
BY
TOTAT
MIN. SEPTIC TANK CAPACITY
WITH DIST. BOX: GAL.
TYPE O
FEE
PE
PUBTIC WATER
CONNECTION FEE
COUNTY BUILDING &ITATION SPECIFICATIONS
DRAIN FIEI.D UIRED
TRENCH WIDTH FTilN.
ZONE
BLDG. SETBACKS _ FT. FROM CTR.
FRoNT fO SIDE INT.
ROAD RIGHT OF WAY
S- slDE ExT' -"REAR {
IC.ANT
SAN ITARIAN Dole PLANN Dqte BLDG. INSP.,Y3r*q
Dqle
Directions to Property:
COPY I - OFFICE
COPY 2 -JOURNATCOPY 3 - AUDIT
Form # css-12
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TRS, T t'(-o5- 22.4. I Bqro Job Location (Street, mile post)1t 6arr^e-gt
^J\PIot Plan Subdivision Lot- Block
FOR SANITARIAN'S USE ON LY:
COMMENTS:
pSvrt., Approved D System Disapproved tl Needs Correction
Signature:k -Ar//,oa:€i 5 -3o.
FOR INSTALLER'S USE: Trench Depth
Tan k Capac ity q OO-- Manufacturer
7C", rirr"tp"p.r'r e"ro* 7.lU,lht. ,*1r"
rrllll t Measured distance to well from tank from drainfield
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INSTALLATION RECORD AND CERTIFICATE OF SATISFACTORY COMPLETION
When signed by the County Sanitarian, this certificate is evidence as per ORS 454.665 of sat-
isfactory completion of a subsurface sewage disposal system at the above location.
Return this form to: Permit Processing Section, Department of Environmental [Vlanagement,
Public Service Building, 125 East 8th Avenue, Eugene 97401
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