HomeMy WebLinkAboutPermit Building 1979-04-20r POST THIS PERMIT ON MAIN BUILDING AT SITE
JOB ADDRESS:I,I7 Pl8.drl Ayc4, k!o., (n CONSTRUCTTON PERMTT + tM?-rg
TRS, TL: l7-01h22{2 r 62O2 Subdivision:
This permit for the referenced property is hereby qryI!'yil. Setbacks and other conditions of approval must be strictly observed. Violation can
result in revocation of this permit, citation under provisions oI Lane County's lnfraction Ordinance, and/or other remedi6 allowed by law.
Applicant/Address:
Owner/Address:
Contractor/Address:
Contractor's OS +r
Construction approved by this permit:
8ay Baaeen, L717 Ptnodala Avanrer fuoeer
JLn Deaa, 1747 Pfoedalc Aveoue, EucsNe
Total Construction Value: pg
, oR 97tO1
oR 97nl *
Telephone:
Telephone:
Telephone:
7174491
747-8491
Repalr falllog SDS.
Stnrcturea Dfl oo ProPertys trm.
Water Supply: il + Bedroomsi rrr * Plumbing Fixtures tre + Employees:na
PLANNING DIVISION Zoning: *Partitioning + rr^.
Minimum required structural setbacks, from: centerline of road, front
side exterior: * ; interior property lines: o" ;rear property line
Special lnstructions:
Parcel +Parcel Size:
; centerline of road,
nena
na
ne
WATER POLLUTION
CONTROL DIVISION
Site lnspection + ," lnstallation specifications: na gal. min. septic tank capacity;
oe lineal feet of rjiainfield required; max. depth of trenches: oe
Special lnstructions:Tlrc hrlld{rrg scret plpe frm houee to tsnk le boredt
Septic Tank
and ir to be replaced. If any algn of fallure prorvafla
after thlr corectloar plcasa contecE thie offlceo1o,-
10'
5',
50'between 8:00 - 9:00 a.m.,63eg Grey
Setbacks
t ^teiio-r property I i nes( Je of road right-of-way
Building foundation
Wells, other water sources
Drainfield--10'-
10'
10'
1 00'For information call
CONSTRUCTION
PERMITS/INSPECTION
DIVISION
Type of Construction: na
lnstructions:
Group: 11a Use Classification ua
For plans information call oa between 8:00 a.m. and 9:00 a.m., 11e
For inspections (see back of this permit) call 687-4065 between 8:00 a.m. and 5:00 p.m.
lane county
Directions to Site:
Date lssued. M-20.79
c55-13
DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
COURTHOUSE / PUBLIC SERVICE BUILDING
125 EAST 8TH AVENUE, EUGENE, OREGON 97401
By: cteg Gray/lJf 6l!'--
For information call 687-4394, rl.-.t.. x-{F
Fire Zone: na
\
t
t
I
,{
+ OEPARTI1ENT OF ENVIRON|4EI,{TAL I1ANAGEMENT ,'^.
PSB, I25 EAST BTH AVENUE
EUGENE, OREGON 9740I p I icat ion r
,11
ing it vrill be used
other purpose. I ha
ser; I essee;
o is knowledgeable o
4,-Etl E
Block __
S igned Numbers
and
ase;
FtntrCi ty -
Township, Range, Section, Tax Lot
Job Address
When
Owner
Subdivision Lot
nAppl ication for
Structures now on the property
Proposed use of prop\erty: N
Affidavit: I,
If this applicat
Lane County Code
Signature/Address
'idential /] Conrmercial
ion is for an agr
nt
bu
ea se
cul tural td
Chapter l0 (zoning) and for no
f7 Industrial /-/ Public
hereby certify that this informat.ion js true and accurate.
d by the State Building Code
ga1 interest in the property
an exclusive option to purch
F
p
'i for purposes allowe
ve the following 1e
holder of
f-TEIs, appl ication.- owner of record; contract Purcha--V-auly authorized to act for the owner, wh
*r A z1 7.
or
permit is ready notify: /-/ Appl icant Owner /7 Contractor /-/ nai
z1 Pho
Con trac tor (zip)Phone
Contractor's OSR#
-
Plumbing bY
# of employees
Te1 eph one Da te
If Commercial: # of stories
Residential: # of bedrooms
SI test holes ready
Descri pti on
Fee
Code
Sq. Ft. or
# of Sites
# of units
SDS: , Existing, BP #
/ / Proposed, SI #
Un it
Cost
$
$
Total Valuation:
Plumbing fixtures at
Sewer/water conn. at
4% State surcharge
Plans check fee
Change of 0ccupancy
$-- each $
g each $
Subtota l
TOTAL
$
/-V't'ash
/-/ Chec \\J
k#
Received by
I,later Supply
Proposed _
Year Instal led
Existing
$
PERMIT PROCESSING Zone Part. #Parcel #Parcel Si ze
Minimum setbacks t , front ,t s ide i nt.rea r
Comments
To be typed on permit
By Da te
WATER POLLUTION CONTROL
Instal lation speci fications
be
ga tank;ft. of drainfield; max. depth of trenches
0n pe t
Te l ephone By Date
Directions to site
Da te
Requ i red
Hcld Slip
to PCC
tlo te
Conrp 1 e ted
Date to
PCC
FOR INF0RIIATI0N about progress of your appiication call Permit Control Center 687-HELP (687-4357)
Valuation Fee
Q
s
{
$
Lt srro Plans to' ::ll
-
setfs)
wru >eut:)
/-/ cP&r-/-/-l{Pc
17 Planning
/_/ PuOlic Works
, Elevation /-/ n/a
/-/ Address
/-/ Faci 1 i ty Permi t
/l Environmental Health
DEPARTIIENT OF ENVIRONI4ENTAL I'IANAGEMENT
PSB,]25 EAST BTH AVENUE
EUGENE, OREGON 9740'I
'I essee;
ble
7r--{*.g \N-rc-
EaO-Ed r=
:*,l,,tyr,,St%*DJob Address
Appl ication for
Structures now on the property
N
Affidavi t: I ,
If this applic ation is for an agri cu ra bu il d'ing i t wi 1
Lane County Code Chapter '10 (zoning) and for no other'purp
er of record;con tract purchaser;. own---V-aut y authorized to act for the own EFt IS
Si gnature/Address
q
ll[U#i:i- istiuo:k:
-/--l i.d. *:Xii /_/ilI rrnj,#f$lliii , i:ffiIit'#iii
hereby certify that this information is true and accurate
I be used for purposes allowed by the State Building Code and
ose. I have the following legal interest jn the property:
holder of an exclusive option to purchase;
app I i cat'ion
lerp)
z1I
1 ephone
When permi s ready notify: /:/Appl i cant
Owner
Contrac tor Phone
Owner /_/
E z1
Da
L
Con trac tor
Contractor's 0SR#Plumbing by
If Commercial
Residential:
# of employees .#lr.:.ilf,.,i'i[tlr.tt ].,,.
rtffiliit , Existins, BP # ----/-/ Proposed, SI #SI test holes ready
$GiIiiiliifi*frri,.
.Ssi,,t.jE'+r,.,iUt, ,&r+t'
-.i+fii:,$,1.tee .Sj{.:Isc
(
I
Total Valuation:
at
at $
each
each
$
$/_t \r33
Subtota l
TOTAL
Received by
Water Supply
Proposed
Year Instal Ied
PERMIT PROCESSING Zone
Minimum setbacks
4% State surcharge
PIans check fee
Change of Occupancy
c
$
Existing _
Part. #Prrcel #-- carcel Si ze-t , front
Comments
To be typed on permit
By-0ate
To be typed on permit
Ey 0a te
PhonpFor plans informati cal I (area
Directions to site o
/_t vro
/-/ CPE'
Pl ans to
set
(s)
(s)
Da le
Pequ i red
tlnld Slip Date Lo
PC,-
FoR INF0RMTION about progress of your .rpnlication calI
c74-L7L
0a te
tlomF, leted
CP& I
LlPC
/:/
/_t
/:/
P1 ann i ng
Publ ic Works
// Elevation /-/ n/a
/-u Address
i_/ Facility Permit
Environmental Health
Permit Control Centq' 587-l"lELP (687-4357)
Val uati on
$---
CP& I Type_ Group-._ Fire Zone_ iJse Classjf icatiul
<b
4/z_
Vlcinlty Map N
TRS, TL Job Locatlon (Addre ss)/ 7c/z l,rte rE
Permit /l
Pernlt
Permlt
For For
Permit For
Permlt #-For
sb 7
tloqr
Permit /lPlcrt Plan For
For
Subdivision
Lot Block
{
-/fii!Y
PrtE Dlr-
Po.
+,
atII
c74-L50
1f
I
/
(
lrTn
-E
rr.+{b=
hr'\{
-ts
(
"ANE couN^ BUILDING pERMtr oR MoBttE H( :
BUTLDTNG [--] MH tr
USE PIRMIT
PERMIT NO.
PROPERTY OWNER MAITING ADDRESS PHONE
CONTRACTOR MAITING ADDRESS PHONE
PROPERTY TOCATION _ INCTUDE POST OFFICE
:
PROPERTY TEGAI. DESCRIPIION - METES, BOUNDS
RA NGE SECTION TAX NO.CODE CENSUS TRACT
,4, A O
EXISTING STRUCTURES ON PROPERTY
APPL.
NAME
&
MAITING
ADDRESS
TEGAT ACCESS TO PROPERTY
PROPERTY SIZE-FT.
WIDTH DEPTH AREA
FOR MOBILE HOME PERMITS ONLY
No. of Bedrooms Connect to Existing Sewoge Sysrem f New System fl
STRUCTURES TO BE BUILT THIS PERMIT TYPE CONSTRUCTION sQ. FT. # BDRMS VALUATIoN
SEWAGE DISPOSAT
PUBTIC tr SEPIIC TANK N OTHERE
PI.UMBING INSTATTED BY
OWNER ! OTHER: NAME
FEES WATER SUPPTY
PUBLTC tr tr OTHER
BUI[DING
WASTE DISPOSAI
PTUMBING
PLAN REVIEW
PARK TRAIIER
TOTAI.
$
COUNTY BUILDING & SANITATION SPECIFICATIONS
MIN. SEPTIC TANK CAPACITY
WITH DIST. BOX: GAL.
DRAIN FIETD REQUIRED
TIN. FT TRENCH WIDTH FT OR SQ. FT
TYPE OF STRUCTURE OCCUPANCY ZONE PUBIIC UTII,. EASEMENT
BLDG. SETBACKS .- FT. FROM CTR. OF ROAO RIGHT OF WAY
FRONT SIDE INT. SIDE EXT.
USE CLASSIFICATION
REAR
AUTHORIZED SIGNATURE - DATE DATE
Conslruction to comply with uniform building code ond counly regulotions
covering plumbing ond sewoge disposol. All buildings require o certificote
of occuponcy before being occupied.
(See Stotement on Reverse Side)
(posT THrs PERMTT ON MArN BrDG. AT SrTE)
TANE COUNTY, BLDG, & SAN, DIV., COURT HOUSE, EUGENE, OREGON 9740I
ronu l* 955- 13
/ 7/7 /zyaoaz{ ,*/C *-*z*
BTDG. PERMIT _ WHITE
OFFICE COPY _ WHITE
COUNTY TAX _ PINK
PIUMBING _ CANARY
BUILDING - GREEN
SANITATION _ GOIDENROD
3r/ a-/-Z*B*z-
1 Z-3/
BU I LD ING S iTE EVALUAT ION
N Building Permit App lication No. JIZ-
( ) S ite lnspect ion
( ) Pre-Permit lnvest igat ion
TJ/Z_R_4Z;_-22-T^x Lo
CE S TRnCf _11= =_.6-.s
APPL I
NAI'18
ADD
PHONE
s
DATE 2*t ?-7_?
LANE COUNTY PLANNING DEPART}4ENT NOT NO YES
appl icabler)
NAI'IE DATE
2-4-a>.I
2
Zon ing 0rd inance Compl iance
(zone_ :\t-7 )
Subdivision 0rdinance Compl iance (
()
(
(
()
()
()
()
()
()
3. Requ i red Access
4. Bu i ld ing S ite (Area, Width,
Frontage, Setback)
5. 0ther (see comments)
V
(
BUILDlNG INSPECTION SECTTON
6. Plans Submitted
7. Soil Stability (footings)
8. Flood Pl a in
9. 0ther (see Cornnents)
NOT NOEill icable--l-T_-( )
YES
*1
()
NA}48 DATE
(
(
{t
y1
fi
)
()(A-lr J- .n
COHI'IENTS:
SANITATION SECTION
Sewage Disposal
Usable Area
Water Supply
0ther (see Corrnents)
NOT YES
N
(
$
()
NA}l8
aool icable*rr--(
)t0.
il.
12.
13.
()
()
,)
(L,
()
()
COHIiIENTS:
TO APPL ICANT:
Your Buildi ng Permit / Site lnspectiV{'Can be approved. 2- t5
()Cannot be approved at this time as indicated on i tem N0.above.Questions and further information on items I through !contact the Lane-COUNTY PLANN ING DEP ARTHENT.Quest ions and further informat ion on i6; 5t hrou contact the Coun t Buildi and Sanitation Divisi on.()t/ill be held in this o ice until Vou can resolve the probl ems n i cated()ls being returned.()Your building permit appl ication fee is being returned under separate cover.
LANE COUNTY PLANNING DEPARTI.IENT
135 Sixth Avenrje East, Eugene, 0regon 9l4}l
PHoNE: 342-t3tt ExT. 231
LANE COUNTY BUILDING 6 SANITATION DIVISION
135 Sixth Avenue East, Eugene, 0regon 9l4}l
PH0NE z 342-t3ll ExT. 4t I
M55- 28
COIVIIT1ENTS:
NO DATE
Date r,Jo.
PERM IT
IN THE BOARD OF COUNTY COMMISSIONERS OF LANE COUNTY
WHEREAS, the attached appiication has been fully considered by the Board of
County Commissioners of Lane County, and it is the opinion and judgment of the Board
that the said application should be granted, and that a permlt should be issued, now,
therefore, it is hereby
ORDERED, that a permit be and is hereby issued to
for the placing, building
and constructing of the following facility:
upon the right-of-way of County Road No., in strict conformity to the exhibits
attached thereto, and subject to all terms, conditions, agreements, stipulations and pro.
visions contained rn the application and permit, the Rules and Regulations Governing
Facilities to be Permitted upon County Road Rights-of-Way, dated March 31, 1960 and
any amendments thereto, and any other applicable regulation, Iaw or ordinance.
Special Provisions:
This permit is revocable at any time, and will be strictly adhered to and no work
other than that specifically mentioned above is hereby authorized.
This permit shall be void unless the work herein contemplated shall have been
completed before
Inspected and Approved
, 19
-.
Expires , 19_.
Approved by Board of Commissioners
By
Date
By
WHITE , OFFICE FILE
GREEN - RESIDENT ENGINEER
PINK
BLUE
Director of Public Works
PERMITTEE ORANGE. BUILDING & SANITATION DEPT
ROAD SUPERVISOR YELLOW - SURVEYOR c98- s2
,
f
Date
APPLIGATION FOR FAGILITY PERMIT
IN THE BOARD OF qOUNTY COMMISSIONERS OF LT\NE COUNTY
Your applicant, ,
hereby makes application under Rules and Regulations Governing Facilities to be Per-
mitted Upon County Road Rights-of-Way, to construct the following facility:
Upon the right-of-way of County Road No., at the following location:
as shown on the exhibits which are attached hereto, in strict conformity to the state-
ments of the exact nature and amount of work to be done, and to the description of the
facilities contained in said exhibits. Your applicant will be the beneficial owner of the
facility as constructed, or otherwise primarily liable and responsible to members of the
public for its proper maintenance, repair, operation and use. Your applicant accepts all
terms, conditions, agreements, stipulations and provisions, in Rules and Regulations
Gwerning Facilities to be Permitted Upon County Road Rights-of-Way, dated March 31,
1960, and any amendments thereto, and any other applicable regulation, law or ordinance.
Signature
WHITE . OFFICE FILE
GBEEN. RESIDENT ENGINEER
PINK . PERMITTEE
ELUE - BOAD SUPERVISOR
ORANGE. EUILDING AND SANITATION DEPT'
YELLOYV . SURVEYOR
Address
Phone No.
IANE COUr\ BUIIDING PERMIT OR MOBILE H E USE PERMIT
PERMIT NO.
PROP OWNER
BUILDING MH
MAII.ING ADDRESS PHONE
CONTRACTOR MAITING ADDRESS PHONE
PROPERTY TOCATION - INCIUDE POST OFFICE
PROPERTY TEGAL DESCRIPTION _METES, BOUNDS
RANG E SECTION TAX LOT NO CODE CENSUS TRACT
EXISTING STRUCTURES ON PROPERTY
APPL.
NAME
&
MAITING
ADDRESS
LEGAT ACCESS TO PROPERTY
PROPERTY SIZE _ FT,
WIDTH DEPTH AREA
FOR MOBILE HOME PERMITS ONLY
No. of Bedrooms Connect to Existing Sewoge System New Syslem
STRUCTURES TO BE BUILT THIS PERMIT TYPE CONSTRUCTION sQ. FT. # BDRMS VALUATION
SEWAGE DISPOSAT
PUBLIC N SEPTIC TANK oTHERn
PTUMBING INSTALIED BY
OWNER n OTHER: NAME
(FEES WATER SUPPTY
PUBLTC tr tr OTHER
BUITDING
WASTE DISPOSAT
PTUMBING
PTAN REVIEW
PARK TRAITER
TOTAT
COUNTY BUILDING & SANITATION SPECIFICATIONS
MIN. SEPTIC TANK CAPACITY
WITH DIST. BOX: GA[.
DRAIN FIEID REQUIRED
tIN. FT TRENCH WIDTH FT.OR SQ. FT
TYPE OF STRUCTURE OCCUPANCY ZONE PUBI.IC UTI[. EASEMENT
BLDG. SETBACKS
FRONT
FT. FROM CTR. OF ROAD RIGHT OF WAY
SIDE INT. SIDE EXT.
USE CTASSIFICATION
REAR
AUTHORIZED SIGNATURE - DATE DATE
BLDG. PERMIT - WHITE
OFFICE COPY _ WHITE
COUNTY TAX _ PINK
PTUMBING _ CANARY
BUITDING _ GREEN
SANITATION _ GOTDENROD
Construclion lo comply with uniform building
covering plumbing ond sewoge disposol. All
of occuponcy before being occupied.
code ond county regulotions
buildings require o certificqte
(See Stotement on Reverse Side)
(POST THIS PERMIT ON MAIN BIDG. AT SITE)
TANE COUNTY, B[DG. & SAN. DIV., COURT HOUSE, EUGENE, OREGON 9740I
ronu lf 655-13
SLAB FLOOR
PLUMBING GROUND/ORK
ApenovEo El DTsAPPRovED
Rrua nx s
GAS PIPING GROUND/ORK
Ap pRov e D
Reua nx s
D r sappRoveo Drrr I ruspecroa
ROUGH PLUMBING
AppRoveo N Drsappnoveo
Rrmaars
DrreJ.///')J lNspecr
ROUGH GAS PIPING
Appnoveo
Rr ptr nx s
I Nspecron
F I NAL PLUMBING
Appnov e o
RrurRxs
DrsappRoveDR
-'
oort f-J -? 3 trspecroR G"Af
FINAL GAS PIPING
AP PRov E D
Reuanr s
D r sappRovro Dare I uspeclon
CERTIFICATE OF OCCUPANCY
Rrrov ro lssur
Reulnr s
D Nor Reaoy ro lssue D Dare I xspecron
oo'.J:r8:2.L- t wseccroe u{/.L
D
D DrsAPPRovE, D Dorr_
BUITDING PERMIT OR MOBILE H EIANE COUI.USE PERMIT
PERMIT NO.BUILDING MH
OWNER MAITING ADDRESS
CONTRACTOR MAITING ADDRESS PHONE
PROPERTY TOCATION _ INCTUDE POST OFFICE
PROPERTY I.EGAL DESCRIPTION - METES, BOUNDS
RANG E SECTION TAX LOT NO,CODE CENSUS TRACT
EXISTING STRUCTURES ON PROPERTY
APPL.
NAME
&
MAII.ING
ADDRESS
rt {\'q\\LEGAT ACCESS TO PROPERTY
PROPERTY SIZE _ FT.
WIDTH DEPTH AREA
FOR MOBILE HOME PERMITS ONLY
No. of Bedrooms
STRUCTURES TO BE BUILT THIS PERMIT
Connect to Existing Sewoge System
TYPE CONSTRUCTION se. FT
New
BDRMS VALUATION
SEWAGE DISPOSAT
PUBTIC f] SEPTIC TANK tr OTHER-l
PTUMBING INSTALTED BY
OWNER n OTHERT NAlviE
BUILDING
WASTE DISPOSAI
PTUMBING
PTAN REVIEW
PARK TRAILER
FEES WATER SUPPTY
PUBTIC OTHER
TOTAT $
COUNTY BUILDING & SANITATION SPECIFICATIONS
MIN. SEPTIC TANK CAPACIIY
WITH DIST. BOX: GAL.
DRAIN FIETD REQUIRED
IIN. FT TPENCH WIDTH FT OR SQ. FT
TYPE OF STRUCTURE OCCUPANCY ZONE PUBIIC UTIt. EASEMENT
BTDG. SETBACKS FT. FROM CTR. OF ROAD RIGHT OF WAY
FRONT SIDE INT. SIDE EXT.
USE CIASSIFICATION
REAR
AUTHORIZED SIGNATURE _ DATE DATE
BTDG. PERM IT _ WH ITE
OFFICE COPY _ WHITE
COUNTY TAX _ PINK
PLUMBING - CANARY
BUILDING _ GREEN
SANITATION _ GOTDENROD
Construction to comply with uniform building
covering plumbing ond sewoge disposol. All
of occuponcy before being occupied.
(See Stotement on Reverse Side)
(POsT THIS PERMIT ON MAIN BLDG. AT SITE)
tANE COUNTY, BTDG. & SAN. DIV., COURT HOUSE, EUGENE, OREGON 9740I
code ond county regulolions
buildings require o cerlificqt€
ronu t 655- 13
PHONE
SITE INSPTCTION
AppRov E o
Reua Rr s
Dts OVED Dare I rusprctoR
FOUNDATION INSPECTION
Appnoveo
Rruanxs '' -
DrsappRoveo Datc ')-- 2 /-73 lHspEcron
FRAMING INSPECTION
Appnoveo
ReuaRx s
d DrsappnovE o D Darr 3 - /tl--I NSPEc
LATH OR SHEETROCK INSPECTION
Aepnovro D DrsappRove o f1 Dorr_
Retqlnxs
I Nspecton
FINAL INSPECTION
Ap PRov e o
ReManxs
rt ,ZDtsappnoveooor, f'f -'? )
z,t -3
C TOR
'u 1- u7
CERTIFICATE OF OCCUPANCY
RErov ro lssuE
Re t"taRx s
Nor Relov ro lssuE
4 tv-tl ?
{s rVt ?,?d*&
Z/^ zoo
r-t
\
D Dore_lxsercron_
Insta s Name
No v
c
INDIVIDUAL SEWAGE DISPOSAL SYSTEM RECORD
nstaller: Complete top part c -orm to
signature and return both copies co Lane
County Building Sanitation Department.
rope SS
upp v
Public D./ otner-List
Cnu I cxsxnrur, RS
Bedrooms Baths Baseftent
yes fl uo il
Ft. from well Steel I Concrete fr-/ No. Compartments
Length width Diameter Depth
GaI. Capacity
sposa
Distribution BoxzYesff No fl
D - Type
Feet from
tion
Lot Line
Front Side
below
AppIi
Name
M ailing
Address
1
ofL
3.
- Et,4. s. 6.
Trench
widrh
Total sqlrt.uetweenl Filler
ft.SHO lri',.= y lrvp" /4
Fi1ler depthabove ,tile A in-
Sketch See instructions
Date
Disapproved
Signature
: System stallation Conforms to Standards
Conform to Current Standards
Date: 4lrs
C.
t,;
rD
LI'\
EGEIVE
FEB 2 ? 1973
LANE C3UII:i fi'rA.LTH DEPI
0
Remarks:
Lane County Building & Sanitation Dept'
Sanitari an
c55-ll
5
For Sanitarian Use OnIY:
IANE COUNTY
PERMIT TYPE - BUILDING
BUITDING PERMIT OR MOBITE
MOBITE HOME iIOSC REG.
HOME UsE APPTICATION
# + , PERMTT Jt
/ l,tltttNo PHONE
747-6
POST OTFICE
.v^'J
PROPERTY TEGAT DESCRIPTION
TOT_BI.OCK-SUBDIV.
RANGE
-d
TAX TOT CODE
DESC EXISTING STRU
METES&BOUNDSDYES
ATIACHED
RES ON PROPERTY IF ANY.
n3
APPI.ICANT
NAIAE
AND
MAIIING
ADDRESS
TO PROPERTY _ ROAD NAME
SIZE_WIDTH DEPTH AREA
FOR MOBILE HOME PERMIT ONLY
Number of Bedrooms Connect to Existing Sewoge System I or New System R.q. E
STRUCIURES rO BE BUIIT TH|S PERMTT
4rnr.r-&A-rr-c,
TYPE CONSTRUCTION SQ. FT.J*d /r-"-,*14rb 4 G,ze-BE08OOM6G)/75? 2-
L#VATUATION
-
Z.*t-aaz.2^t*rltk/-Src el-do o6E
-7 7
//
PTUMBING INSTAIIED BY
OWNER OTHER E NAME
PLANS FURNISHED
PUBLIC SEPTlC OTHER trofEES WATER SUPPT_Y FAC ITITYBTDG.
WASTE DIS.
PI-UAABING
PTAN REVIEW
PARK TRI.R.
PUBI-IC OTHER YES
s
NO
OF APPTICANT
BY
DATE
7
DATE
-/3* 73
YES NO
PIUMBI
//
NG FE
FIXTURES
TOTAI./3o Jo
cAsH E
CHECK NECTION FEE
PUBI.IC WATER
CONNECTION FEE /-
COUNTY BUII-DING & SANITATION SPECIFIC,ATIONS
AAIN. SEPTIC TANK CAPACITY
WITH DIST. BOX: GAL.
DRAIN FIEI,D REQUIRED{oo I.IN. FT,tffi TRENCH WIDTH FT 3 oR seuARE rEEr 37y'4
b
/ra in*tu Ao nfr >
OCCUPANCY
-sIDrEXr:-
TYPE OF STRUCTUNE
BIDG, SETBACKS _ TT. FROM CTR. Or ROAD RIGHT OF
ZONE REAR YARD
USE CI.ASSIFICATION
PUBTIC UTIL. EASEMENT
T
FRONT SIDE INT,
Direclions to Find Property:
REAR
e--la
Dole INSP.
torm $ g55-12
'.2 Dole
COPY I _ OFFICE
COPY 2_JOURNAI.
COPY 3 _ AUDIT
TWP sEc.
Jo. r.oJG 4o
Z 7