HomeMy WebLinkAboutPermit Building 1981-11-17FOR OFFICf, USE ONLY
CONSTRUCTIU LACEMENT
PERM IT
COIIPLETE THIS BLOCK. PLEASE USE BLACK TNK AND PRINT.
PLANNING ZONING z zone
Applicatio
:flts!fre-Copj,es of Pfans
fl Tro Copies of Plot Plans
f] l.lechan j-ca1 Checklist
frlumning Chec]:1ist
Plan Check Info Sheet
Partrticn i Parcel #Parcel size
7 tt4,Z LorlPAR'EL
G<
BLOCXI5
E3e sidenr-i al n tndustrial
flnuuricCommercia
foF -/,l--l Proposed
frg.i.t:."e
NU}'{3ER
THE COMPLETED APFLICATION FOR PERI'IIT, and do hcrcbT,rottifi'thot aIl inf.)rmation hcrcon is trrrc and correct rrtd I flrrtl)cr
I performed shall be done in accordance with the Ordilralcos of Lane County and the l,ans of thc SL.rr_e of Or?(l.rn I,,_.ftair)in,land that No oCCUPANCY uill be nade of any structure without the permission of the Building Divislon. 1 furth{rr c:r rtity
rilder's Board is in fulf force and effect as required by ORS 701.055. that if exenpt the basis for cxenption is not..d
.ractors and emPloyees who are in compliance with ORS 701,055 will be used on this project. I HAr,rE READ AND CIIEC],.ED THIS
d-,l or,.e,
SIGIJATURE fl es..t
<^
2-E(qontrac*-o:
NA-["IE (p]ease print)
L//t r" .AREFULL, EXAMTNED
/c{tity that any and all work
/o *e work described herein,
that. registration with the Bu
hereon, and that only subcont
APPLICATION AHOROUGHLY.
Iulinimum Se
lnstal]ation
Specifications:
Colunents:
C L,C L t idc.interior re ar
tr PLAIN:
I nunal ADDRESSING: CRID COORDINATE N
I samrtATroN: s. r {
In flood hazard aruaz Ff lto I ves, see attactled sheet
Date:
Date:
Date:E
B. P. #lnstallation Record Issued? [ v.= f] no
Maximum Depth
of 1'.rerrche!l
GalIon
Tank
Lineal Feet
of Drainfield
Date:
{r"*l ,rn" V -Al ",",n ?-trirl-l ,,"V€z,]tilllZAt-EXAMINATION:
Conunents :
xed
Uni-t C
Fee/
ostfr
Floodplain Fee
Subsurface Fees
Building Fee
FEES PATD BY
By:
Date
3-@$
)
$
$
$
fun%-Seweg/Storm Drain/Water $/. rr*iT{Q,-$,'""1&
H::T::{?,ry"*/
state surcharge 4lZ
rorAl PIIE 99.54 $43,/
TOTAL VALUATION $fl cas.Fe Do€-tf 74.?g
PERMIT APPROVED BY BUILDING OFFICIAL/DESIGNEE (per ORs 456 (1) )DATE
LANE COUNTY DEPARTMENT OF ENVIRONMENTAL MANAGEMENT / 125 EAST EIGHTH AVENUE, EUGENE, OREGON 9740L
c74-t94 SEE REVERSE
^"'22
PROTOSUI] USL OF PROPERTY
tr
tr
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)
\
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SETBACKS AND OTHER CONDITIONS OF FIrPROVAL MUST BE STRICTLY OBSERVED. VIOLATION CAN RESULT IN REVOCATION OF THIS PERMTT;
CITATION UNDER PROVISIONS OF LANE COUNTY'S INFRACTION ORDINANCE, AND/OR OTHER REMEDIES ALLOI,IED BY LAt.l.
WHEN READY FOR INSPECTION CALL.687-4065. A MINIMUM OF AT LEAST 24 HOUR ADVANCE NOTICE FOR INSPECTION REQUEST MUST BE
GMN. Have the following information ready: Permit numberi job address, type of inspection, when it will be ready,
your name and phone number, and any special directions to site.
BUILDING DIVISION:
REQUIRED IIISPECTIONS
f) F0UNDATI0N INSPECTI0N: To be made after trenches are excavated and forms erected and when all materials for the foundation
ffiob.Whereconcretefromacentra.lmixingplant(common1ytermed..transitmixed..).istobeused,
materiais need not be on the Job.
2) CoNCRETE SLAB 0R UNDER-FL00R INSPECTIoN: To be made after all in-slab or under-floor building service equipment,
EonEult, piping atcessories and other ancillary equipment items are in place but before any concrete is poured
or floor sheath,inq, instal led, including the subfloor.
3)FRAMING & INSULATION.INSPECTIOf{S: To be made after the roof, al'l fram'ing, fire blocking and bracing are in place and
sandventsarecomp1eteanda.llroughe1ectrica.landp1umbingareapproved.
walI irr"ulation and vapor barrier are in place.
4) LATH AND/oR GYPSUM BoARD INSPECTI0N: To be made after all lathing and gypsum board, interior and exterior, is
but before any plastering is app'lied or before gypsum board joints and fasteners are taped and finished.
5) FI!!! !tlSP!Cl!0lI: To be made after the building is complete and before occupancy.
All
in piace
APPR0VAL REQUIRED. No work shall be done on any part of the building or structure beyond the point indicated in each
successive inspection without first obtaining the approval of the building offic'ial. Such approval shall be given on'ly
after an inspection shall have been made of each successive step in the construction as indicated by each of the inspections
requ i red.
N0TE: Al1 building permits require inspections for the work authorized, such as but not'limited to:
A. BL0CK WALL: To be made after reinforcing is in p1ace, but before any grout is poured. This inspection is
required for each bond beam pour. There will be no approval until the plumbing and electrical inspections
have been made and approved.
B. W00D ST0VE: To be made after completion of masonry (if applicable) and when instal'lation is comolete.
Installation shall be in accordance with an approved nationally recognized testrng agency and the manu-
facturer's instal lation instructions.
C. l,l0BILE HOME: An inspection is required after the mobile home is connected to an approved sewer or septic
system for: setback requirements, blocking, footing connection, tiedowns, skirting, and plumbing
connecti ons.
(f) Footings and piers to compiy with State foundation requirements for mobile homes or as recommended
by the manufacturer.(2) Mobile home minimum finish floor elevation sha'll be certified when required by a floodplain
management Ietter.(3) l4obile home tiedowns, when required, and skirting shall be installed and ready for inspection
within at least 30 days after occupancy. Tiedolvns and skirting shalI be installed per enclosure.
D. SWIMMING P00L: Beiow grade when steel is in place and before concrete is poured. Above grade when pool
is instal led.
APPROVED PLANS MUST BE ON THE JOB SITE AT ALL TIMES DURING I,IORKING HOURS. THIS PERMIT WILL EXPIRE IF I'IORK DOES NOT BEGIN
I,IITHIN I8O OAYS, OR IF I^IORK IS SUSPENDED OR ABANDONED FOR MORE THAN]8O DAYS. SUSPENSION OR REVOCATION MAY OCCUR IF THIS
PERTIIT I^JAS ISSUED ON THE BASIS OF INCOMPLETE OR ERRONEOUS INFORMATION.
ANYONE PROCEEDING PAST THE POiNT OF REQUIRED INSPECTIONS I,JILL DO SO AT HIS OI'IN RISK
SUBSURFACE AND ALTERNATIVE SEWAGE DISPOSAL SYSTEMS
Permits shall be effective for one year from the date of issuance.
Upon completing the construction for which a permit has been issued the permit holder shal'l notify.the
Dipartmeht by submitting the installation recbrd form. The Department shall inspect the construction to
delennine if-it compliei with the rules cqntained in, this division. If the construction does comply vtith
such rules, the DepirAnen?bfiatl,issue a iertift.eate.of satisfactbrycompletion to the perm'it holder. If ther
construction does hot comply with such rules, the Department shal'l notify the permit holder and sha'I1 require
satisfactory completion before issuing the certificate. Failure to meet the requirements for satisfactory
completion wittrtn a reasonable time constitutes a violation of ORS 454.605 to 454.745 and this rule.
(r )
(2)
Setbacks - Subsu
From:Interior property l$*=:..,.,*.r.* P:-
Edge of road qight-of--vlay-' ' ' - l0': - -"'
Bui]ding foundat'ion 5'
Wel I s ,. ,other ,water sources 50'
'10,
'100'
Drai nfi el dlTo-]--
lane county6l!'\-
CHECKLIST
PIUM BI NG / TUIEC HAN ICAI
Y"Laa"oLq
LJ
APPLI CANT INFORIvIATION :
OI rm-ease
PLT]MBING CONTRASTOR
MECHTqNI CAL CONTRACTOR
C.-c,-o
Yes Firm
Address
tr No n
1ng
Se r.r-
SS r
o Cont. OSR#)O - ty? FB
6 Self
Firm Cont. OSR# 2U IY
Address
fl Nofl serr
PLIJMBING
OFFICIAL USE ONLY
App1i./
Permit #zw
Tlpe of Fixture Number of Each Fee On Each Total
Sink $ s.o0LavatoryAS1ns. 00
Tub (with or without shower )5. 00
Showcr, separate 5. 00aterosettoI
s.00Disposer t e r s. 00
)b s. 00 40.oo
_Sewer--lst 50ft.15.0
eaEh additional 100 ft.10.
Water Service--1st 100 ft.15. 00
each additional 100 ft.1
Storm and Rain Drain--1st 100 ft.15.
each additional 100 ft.1
Special Wqqte Connection s .00'ejector 5.00rl)
Other c1 STorlnotTAnr Y,tox f+
SIIB-TOTAI (Minimum $10. 00)
TOTAT FEE
MEGIANICAT
Type of Equipment l{umber of Each Fee on Each Total
Mechanical Permit Base Fee $ 10. 00
Furnace up to 100,000 BTU/H I $ 6.00 /P
Furnace over 100,000 BTU/H 7. s0
Qlothes Dryer Vent 3. 00
Bathroom Ventilation Fan & Duct 3. 00
- Range Hood with lvbchanical Exhaust 4.50
Wood Stove 6.00Air Conditioner Only 6. 00
_ Heat h.unp 6.00
Floor Furnace 6.00
Gas Piping System 1 to 4 Outlets
Per Outlet 50
Other (specify)
SIjB-TOTAL tb.&
TOTAL FEE
5. 00
rer
ng Machine 5. 00
AA .er
). 00
r. 00
e .00
lone counlyEnuironmental Management
ACTIVIT ^ INFORMATION SF'T.ET 6r\-COMPLETE THIS SECTION. INCOMPLETE FORI4S WILL BE REJECTED:
o OL s Rohe*T 114c C \ e \\ a- ^PROPERTY OWNER/CONTRACT PURCHASERAPPLICANT
5s q [ri t \ o v.., s-[[ e, Et.385 \/ oL n-*A *
IVI.I\ILING ADDRESS MAILING ADDRESS
9lqo 1L{ \ f)&e \
1I STATE ZIP CODE ClTY STATE ZIP CODE
u1 gu1_loS3 \:"r - B6ro
BUSINESS TELEPHONE NUMBER /UOME TELEPHONE NUMBER
@ uerr, rNFoRr,rATroN To: gd6elrcaur,/REPRESENTATTvE
ffi HOME TELEPHONE NUMBER
I enoennry owNER/coNTRAcr PURcHASER
@ rax MAp/pRopERTy DESCRIpTION NUMBER (from tax maps in Dcpartment of Assessment & Taxation or from tax statement):
Tax Map Number / 7-o 2 -/?-3 Tax Lot (s) :
I out of TL # By partiti-o. ll-
Tax map nurnber of adjoining property in same ownership: !Xone I Unk.town
Tax Map Number:Tax Lot (s) :
@ SuaorvrsrON (if applicable):BLOCKi _ LOT:
@ ngOUBSt (brieffy cescribe information needed):
e
@ torer, coNTrcuous PRoPERTY' rN sAi\lc oI^INERSHTP acres
@ enoernrv ADDRESS
@ rnesaNr usE oP PRoPERTY:R*=
@ r.tuuarn oF srRUcruRES oN
Modular home -
Garage-
I
PROPERTY: Standard home I
RV in use as residence -
Shop '-
MobiLe home --
storage -
Barn
Other (specify)
@ eCcuSs TO PRoPERTY: Public Road Name YoL ct.Aa-
Private Road Name
Road Easement width
#of
Use rs
@ orusn EASEMENTS ovER PRoPERTY:
O tvntt;lt o I s't'RrC'l :?-.w.q-_R
O rlxrs'I'lNG PERI'lrrs oN PRoPERTY:
fuo
@ rrna DrSTRrcr:
COI\,IPLETE THIS SECTION FOR I,AND USE,
CONSTRUCTION APPLICATIONS ORP *NOTE **FOR STAF US ONLY**
NUMBER:
DATE:
TIME INITIATED
CHECKED BY:
ATTACHED E
fl erot plans (2)
f]constr. Plans (2)
flsite etan
fl copy of Tax MaP
X oar,"r-
SCREENING VERIFICATION :
P1' .D1 .
Date:
Ti.me In Out:
f]accept
Routed to
*NOTE:
I neject
ATTACH A COPY OF TAX I'IAP;
SHOWN EXISTING STRUCTURES
AND TAX LOTS IN YOUR OWN-
ERSHIP. OBTAIN TAX MAP
IN SELF HELP AREA.
Fa
Na
€tr
-7 /et (ovER)
_sf.
CO!4PLETE THIS SECTION E'OR I,AND USE OR
@ enonosrD usE ou o"ope*rrX DETAIL:
S-xa.u.---Ll"eL.11r4,[qr.-
IONS **FOR STATT USE ONLY**
Rw.
Date:
\
o BUILDING REQUESTS:
Contractor's #3 b?. t:1_
Directions to Siter Errr \^r\,o-N
(for mobile home setup also)
Time In:_ Out:_-
I eccept ! neject
f] nlanning Application
! Construction Permit App.
f] tnformation onty
Zoning:
Comp. Plan Designation:
Check the type of permit'reguested:
l-l owellins: ft rvew ! neptacement
f] aaaition ! Alterationi
Iuodular Home f]uobire Home - Model
fl ov ! standard Constructioni
fl er.r, check only
[l commerci-a1:
fl asricultural:
Cofiunents
SANITATION:
By:
Date:
Time In:_ Out:_
f] accept I nelect
! Constr. Permit Issue
! site Evaluation rssue
PERMIT TSSUED (SA]'lE DAY ONLY):
Permit #
By:
Date:
Time fn:out:
f| additional;
Year
Use Floor Are
Use
Ploor Area
[-l cr,u.,g" of use - How?
@ saNrrnrroN REeuESrs:
f] sit" evaluation for SDS feasibility
f] uew system j-nstallation
! nePair,/rePlacement
f, alteration/re locatiort
[_J Hook to existing
ADDITTONAL INFOR}IATION: .
ZONE,/LAND USE:
UK",s, u." Sn\^- fa--u.(n
lane countY
HOLID StIP
APPLICATION # Z \
LOCAT I ON
64q t^J,, , o,
NAME
ADDRESS
E
The above application is being held for the followin g reasons
I .?gott*. ;ryf,lFLc*TloFl., DY Arl wpN A?i+{l-(€cT oE" aql^I&-)
THAT T+IE, EXt rAJ q hl,a- 3wrclq mt
Otr ]H€,
xl€, aY
NaTWc[1O^I5
3. ftov tDa A
4.
R
v(
6,
?s.
MAf.r uFilcTrl ze:Pe I NSrNJ*I1ON
aN f?-a^t 3-
TH€ PUILD lNq LX,N]Il.lr1 X+€
il "?f,-8 I
DATE
hl6]6l+T.
Z.?q,r^t',Dq-
trL
This app)icat'ion will be held unti I t/Aht- If the jnformation required
above has not been furnished by that?ateloui +plication will be cancelled.
Building; fees paid for permits cancelled under these cjrcumstances wjll be prorated
according to the work that has taken place as of the date of cancellation.
Kqurul T\lts e-tP t,{tT+l TH€ qugsTw tNrcR-p1,NnoA.
BUTLDING & SANITATION / ENViRONMENTAI- MANAGEMENT DEPARTMTNT
125 Easr gth Avenue / Public Service Building / Eugene, 0regon 97401 / (503)687-4061
?=8b Yu*'tr
Mr@
Anaxe.Oz.
KV) NNT.IN3
OFF]TE_N-OUXS
lane countyHOLID SLIP fi!'--7
APPLICATION # :-8r
LOCATION
Mr cxaeL NoBwooo NAME
ADDRESSWr ttaugrre
.* U,rn**.. U*.
Zrp eOrU
The above application js being held for the forlow'ing reasons:
Txt anlcrng Foi n{E RooF RAFTERS cAUSE TxE ctrltNc Jorsrs ro FArL.
PeovtoE REvlgroxs yo rHE noor/cerLrr.ro FRAxrHc, DEgTGNED By Ail Onecou
ARCH
Sprc
Pnov
r. E.
TA XK
Spec
z&.z
Txr
D
3.
)+.
5"
,rft/fi'
OVER
OES I
SY ST
GN LoADs. Pnov r DE E I TIIER THE uAilUracr r RER' s oRAr., r Nc FoR txE(luoooRi
fr,r oR REVTsE THE pRoposEo suppoRr. Sec. Z&t (r)
1?lo l8t
S IGNATURE
58?-\o6r (t-\ oN,-v)
OFFTCE HOURS PH()NE
This application will be held until
-
If the jnformation requiredabove has not been furnished by that-date Vour appl'icatjon will be cancelled.
Building fees paid for permits cancelled under these circumstances will be proratedaccord'ing to the work that has taken place as of the date of cancellation.
BUILDING & SANITATION / ENVIRONMENTAL MANAGEMENT DEPARTMENT
125 East gth Avenue / Publjc Service Building / Eugene, 0regon 97401 I (503)687-4061
5
lane county
APPLICATION # LC ,Br
LOCAT I ()N Yot- l ruoa
MrcxlEr- Nonwooo NAME
ADDRISS5j9 Ulr LLAMETTE
--*ntot' o*'
zru eoD,
The above application is being held for the following reasons:
4. Txr enlcrNG FoR THE RooF RArrERs cAUSE THE cErLrNG Jot
FnovrDE REvrsroNs ro rHE noor/cerLrNG FRAMTNG, DESTcNE
/. aRcn rrEcr oR ENG T NEER. Sec. 3OZ(c){..1pecrFy rHE MoDEL or coLLEcroR ro BE usED. Src. 3Oe(e)
{ e*ouroE AN ELEVATToN AND scHEMArrc prprNG 'LAN FoR rHE
HOLID ST,IP
t.t. t PIPTNG FROM THE WATER STORAGE TANK TO b/HATEVER
t/. r^NR', Src. 3Oe(a) t1t-o .^^cLu* "- -F*,lr {4- L\+t
+. )PECIFY THE SIXE AND DESIGNATJON OF THE OROPOSED RIV
{ ln' $1, r },,, r / s,7i,]I.lif/i',,,7i*^;=# ili^,ff
dt r lt'D
/u --\''o-
(
STS t
DBYAN
PROPOSED SYSTEM,
I S SUPP IED BY TI.{E
ETS.5ec.Joz(a)a
*t.t"-6A *Yoa t')
ORATORS APPEAR TO BE
ovERSpANNED, BASED ON THE ALLOWABLE ALUMTNUM BENDING STRESSES AND THE
DEs tGN LoAos, Pnov r DE E I THER THE MANUTAcT r RER's DRAvr NG FoR 'THE suppoRT
sysreM oR REvrsE rHE pRoposED suppoRr. Sec. z8or(a)
-t\ bou r .-Tr t'tr'x t'li'xr/r"
,,.L.trf4^tt
d",?-3Y( d.I{*{-
l.-*.- ; *";J"'[ '
A4
S IGNATURE
NO WALK- INS
. tz/ot /Bt _
DATE
68l-405t (t-4 oNrv)
PHON EOFFICE HOURS
Th'is application will be held unt'i 1 tz/zt/Bl If the information required
above has not been furnished by that-dtte vouf-ipplication will be cancelled.
Building fees paid for permits cancelled under these circumstances will be prorated
according to the work that has taken place as of the date of cancellatjon.
RETURN TH 15 SL IP V/ITH THE REQUE'sTED INFORMAT ION
BUILDING & SANITATION / ENVIRONMENTAL MANAGEMENT DEPARTHENT
125 East Uth Avenue / Public Service Building / Euqene, 0regon 97401 / (503)087-406]
B!ilCing Pernit-"ry1;:e
CrJl:/ T;r-Pink -plrrb-. -_,:, ir.f--
Builc,.i-Grao
Sani tiI iaft-Go l3e. rod
Fite Marshall-Buii
s
L&EqH effieJrdYyi ewnum$&Bs PERF*qEY
I
Lone County Courtho*e, Eugene, Oregon 97401
Ovrner IJYT0SKI , John A. Moiling Address
Controctor Moiling Address
Locotion of Proposed Buildlng (ond Post Office):
3385 Yolqnda AYenue
Existins Sir-r.ir.et ;;'i;;;;tiii*'--- *o lf so' describe: CT- "20- qOt
Do.. jrop"rty hove legol occess? uat lf- so' describe: Yolanda Avenue
Legol Description of Building Site - Mdtes ond Bounds
Acldltion to l'lontebello Acres
uS7q{c"a"
Areo
Squore FeoPge ryff-"f ct":tt"tl*
Lot I and 2 Block 3, lst
T*p. ll Ronge 92 Sec. el I w.4*
Size of PropertY:\A/idrh DeP th
Structures to he buih under this Permil:
D:rrelling, llving area maln
&Atached garager celled
Recreation area over garage
1473 @ $ 12.
I public water I septlc tank connection
!nstal I set+age di sPosal system
G$eirvie'* Street, SPrlngf iel 7r$-59e0
Bdrnrs.Vs!uation
r325 Bhone
$hon*
h{o.F$r-LeaA
t7,676"
I ,936.
{,olq)
r*ood frame
; Driven
,1.
@ $3.50
@$12.
553
56s
proposed VrrP.l''gfr'dlp, r i p3611e s
Proposed Sewoge DisPosol: Public
Plumbing io be instolled by Orvner (
; Spring
; Septic Tonk
Plumber ( )
; Well: Drilled
- ; Pit PrivY
|Gme of Plumber,
; Dug
FEESI
Building
Woste Disposol
Plumbing
Plon Check
$g&.oo
7.00
l9,oo
7 ft. PUE on back of both lots
tdest side of lot I
/cl liary t'fytoskl
Signoture of APPlicont Dote
TOTA.L
SANITATION:
Septic Tonk: A{inimum Liquid Copocity
Subsurfqce Disposol Field Required:
wirh Distribulion Box
Lin. Fr.
2t$
1000 Gols.
Width of Trench, or
3ft.
$
EffiEJNYY B&"$gLffig$\$& & gANETS-YB@N SPHffiBFECA
, ,'8Y
Sq. Ft. -
7?0
lnstall a fill thiee feet deep co*taining no
gr*den loafl. Keep trenches ?0 feet frcnr edges
trenchcs l0 feet apart.
rock, sar:d, or cla'/.
of fill on a!l siCes
0[CUr]A],1ieJ
Dote
TARIA},i
Use
5ri
STR,UCTURE:
Zone AGT Bldg. Setbocks: Fronl l+5tfeer from Cenler of Roqd. Side, lnterior !l Feeh
Exterior (if corner lot) 40.1 Feet frorvr lenter of Rood'
CONSTBUCTION TO COT.,IPLY UIITH Ui.JIFORM BUILDING CODE AND STATE HEGULATIONS GOVEBNING PLUMBING AND SEW'
A.GE SISPC)SAL. ALL COMiV'IERCIAL P.ND INDUSTRIAL BUILDINGS BEOUIRE A CEBTIFICATE OF OCCUPA}ICY BEFORE BEIT*G
OCCUPiED.
Ap crtlon,of the work covered bY this pcrmit shall be started within 60 days from dlte and irll work completed within one year, except sewage
disposa I repair, which rnust begin inrrnediately lf not, the permit beco nless renewed by the cclunty building insPector.
B't'
IEVa 6.W'rtlli S{GNID
Rrrt nl"u.-. ;1.,
$Y Tri:
NG.I'
sAt't
tr t,i.j#,tttl*Fr?.ro*.,,,,.Gioo*,'--ts"Ui rilt lnrl+s p.Rr,irr rcF. Tl{t rrr*.ru*ru?.T:}S'"I$ro*.
Tlt!5 Pri:&uT lfi A P;tQ,*ll.,l ENT LOCATIf}II O}.I OR T.DJACENT TO THt ltlAltn BUllDti{G AEING COF::T;{UCTID
P05?
1I
,#2
Recor d- {- rndividual s.;;rre Disposal syster.n
Ig" BE*-PERMrr COMPLETED BY INS TALLER:
ISSUED TO:John A-l^/y tos k i
.:..t
lnstoller's nome
Norn
Moiling
Totol n
r#oter s
. Euilding permit number 75-70
unrber: Living units_ Bed
Property oddress
Lot I anC )Block 3 lst Add to Hontebello
Septic tonk: Dii tonce frorn wel
,oors '. ''
B oths-=.-Bosement: Yes NN oI Acres De Greeupply by : Public system .' -' lndividuol system_ Communi ty system_=._-_
Totol liquid copociDiometer ft Liquid deptTile disposol field: Distribut ion box? YeLength eoch line
Totol length
Width of trench
Totol squore footoge
Distonce between tines
Typ"of filter moteriol: Grovel
Feet. M s terio No. of comportmengol. lnside length ft. lnside width ,:i ftft
Oth
ft.
er
Distonce from:ft. w feet.ft. Neorest
Dept h of filter moteriol oyer tile inches
[t. Lot line:Front[ SideI Reorfi _feet.,/a it Foundotio feet.Other---------.-.___. Depth of filter moteriol beneoth til
SKETCH (See instructions)tt
u1" l
r,)I
I
fa ,iir iT I tirj ii
iL:" l I li" ii i1; it-m
, iii I 1 '/ 13i0
L^{i,iE [L]lji'ji] HEALTii Ui,:11
TJov l!
;N F,LL
5<//:
4 )
)
BE SURE TO INDICATE NORTHERLY DIRECTION
Do
FOR USE OF SAN ONLY:
System opporentty
Remorks
ITARIAN
wiil1b function sotisfoctoriry, ond is therefore opproved for occuponcr ff DisopP.oved'ff
Signo tu re
ARTMENT
@r
6
will not !
LANE T
SANITARIAN
!)c *1
W)/'
t 1'-t i
---*?3-
I,AI{D FILL EVALUATION FORI{
Nane l-4) r, /.,.s ,{-"
Date
Townshlp
Bange
Sect 1on
Perurlt No
-1rr
Iotlt
t I tql
Eouse No.cltylP. o.
Rte. No,
v-
otAtt*t Yr.fu
F1e1d personnels lnltal oPlnlon
I
rr.
III.
Slt"e condltlonA. Slope by lncllnometer
" O-5 sllght' :-5-!5 moderate
_L5-25 severe
solI depth-:----Tapp1ns unlt :---E o
B. So11 e. Sub so11
typetatle
FIlI cond.ltlon
3 r _depthA. E€latlon toglequal toless then
D. Type of ftIl
oart ta1
_{ coap}ete
ye
-{no
System condltlonA. Satlsfaetory3i_Fa1l1ag_{ resldentlal
-r&group resldentlal
commerc 1a1
-lndustr1a1
French draln
age Lqo.--0 mater laI used ln f111
B. Conpactlon C, Vegetatlon
meets speclflcatlons6v""no
Percolatlon test
8.f111 materlal
b se naterlal
Yes -Y'nat lve
Q"" -Planted
JE. On slte materlal F. Cond.lttont
-r""
-Aeooa. -_no . nat8lnar
_POOr
_fuo. ."63fi[Ht'3','
water table-ZFnyslca1 evldence( good. )
-physlcal evldence ( poor )
grade
s
IV Procedures ln data gatherlng
Dhotoeraphs No.
-chem16a1-
-No.
-bacterloTi@No.
,
Remarks