HomeMy WebLinkAboutPermit Septic Tank 1986-03-28G.G
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Lane County Authori za,ttot't' for'
SEPTIC DISPOSAL SYSTEM INSPECT ION FOR LN. RV.
@sEoNLy
Aoolication/
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03
RANGE 2WSECTION
5t 00
TAX LOT f]our oF'!CW}:SHI P
17
LOTIPAR,qEL BI,OCKSJBDIVISION/PARTITION (if applicabJ.e)
PROPOSED USE OF PROPERTY
pldl:.aentiar
[-l commercial
fl rnaustrial
PubIic
2819 N. 3rd St., Springfield 97477
I,OCATION ADDRESS CITY ZIPSTF.EET
R.ES
Rd. - No. 3rd St.n Brid
Y
NofH
DECI,ARED S VALUEDESCRIPTION OF PROPOSED WORK - BE SPECIFIC
Septic insoec. for In. FHA
hiATER SUPPLY Proposed
Exis
# OF E!,IPLOYEES= OF BEDR.OOMS f OF STORIES
TELEPHONE NUMBER
687 959.1 746 630YAPUNCICH, Roberta
OiTNER'S NAME AND ADDRESS
same
TELEPHONE NUMBERCONTBACTORS NAI.{E AND oSR *
TELEPHONE NTIMBERF:FIIITTO BE MAILED TO (NAME AND ADDRESS)
I HAVE CAREFULLY EXN,IINED THE COI,IPIJTED APPLICATION rOR PERMIT, ar'd do hereby cettify that a]l infomation hereon is true and correct, ild that r
have the following legaL j-nterest in the property,ffiorn". of record; !contra.,! prrrchaserif,authorizetl agent.
I f:rther certify that any and all work perfomed shall be done in accordance uith the ordrrlances of tane coMty and the Iaws of the State of Oregon
pertaining to the work descrj.bed herein, and that NO OCCUPANCy wi.ll be made of ani' strlrcture without the Pemission of the Building Division. I fur-
ther certify that registration with the Builder's Board is in fu1l force and effect as required by oRs 701.055, that i.f exempt the basis for exemption
is noted hereon. and that onLy subcontractors ad enployees who are in conpllance with oRs 701.055 will be used on this Project. I HAVE READ AND
CHECKED THIS APPLICATION THOROUGHLY.
E RTno
READ THIS SECTION CAREFULLY. YOUR AUTHORIZATION IIAS BEEN BASED ON THE FOLLOWING CONDITIONS !
zone- Partition #- ParceL #- Parcer site-
Installation
sDecifications: Tank
ION:
DaLe:
Gal10n
c0r'LrlENTS
Date
tr
3-er -16
II I RED.ING ACTION RNO SPECIAL P
B. P- #SANITATION: s. I. *
Group UsePLANS EXAM
Minimum setbacks:
col$1ENTS
interior rear
I pmutlruc,zzoNrNG:
Lineal Eeet
of t)rainfi-eId
rnstallation Record rssued? ! vu= ! *"
Maximum Depth
of Trenches
Dare: g- 2o-P6
cL. fro.t-c __L, Slde
APPROVED BY
LANE COUNTY
3
IGNEE (per oRs 455.805
ENT OF PUBLIC WORKS LAND MANAGEMENT D]VISION, 687.4061,
125 EAST 8TH AVENUE, EUGENE, OREGON 97401
SEE REVERSE FOR INSPECTION INE'ORMATION cL4:25 RW
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-tt--DA'rE-
T
ldne coLrnry
ACTI .ITY INFORMATION SHEET
COMPLETE THIS SECTION. INCOMPLETE FORMS t,JILL BE REJECTED!
ilI'\rE,
I
I"IAILING ADDRESS
Stt-,,- *F,*' t' QTY.-..C
?tuq- DyLE SL<A
PRO E
S a--?"<--4-
MAILING ADDRESS
E sz-zs= i 7 6 3 d
BUSINESS TELEPHONE # H TELE
€ z U'->
7
/ - CT4Y-
At7 ?s-7 I
STATE ZIP CODE
7y'6- GP a4ffi FOMilTE-LEPHONE#
2 PRoPERTYADDRESs &El? "/o -7*4(IF DIFFERENT Tno@ rF ,/ r-
3 ruap sl, PArtcEL NUMEIEFI
(R UrRED INFoRI4ATI0N)
MfrNSH-TP. MNGE SEETI.ON
TOTAL CONTIGUOUS PROPERTY IN SAME OWNERSHIP:
(from tax maps in Department of Assessment and Taxation
or from tax statement)
tto rE| FtL€ #fr* Rft# #frtt 051aoTATIOTI' 0R PARCEL # ZONING
TOIISMF NANGE SETTION TAft-tOTfSI oR PARCE-L #ZONING
TAX-IOrfs) On PARCEL # zoNrNG
ACRES
LOT BLOCK4 SUBDIVISI0N ( if appl icable)
5 REQUEST (state exactly what you plan to do)
6 DiRECTIONS TO SITE
** FOR STAFF USE ONLY **
ZONE/LAND USE:
BY : _ DATE:_ TIME IN:_ 0UT:-
NUMBER
DATE
--{F(/,
{l-
d-"-_
LAND MANAGEMENT DIVISION / 1?5 E. Bth AVE FUGENE, oR 97401 / 687-4061
P^h p r-*,+ t4 'l,l * pu t/ t-t o +t-
STATE ZIP CODE
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