HomeMy WebLinkAboutPermit Building 1977-07-25TRS, TL JOB LOCATIO
LANE COUNTY PERMIT
Acreage or Lot Size
Contractor's O.S. #
Partitioning #
OWNER'S NAIVIE AND ADDRE
Mail permitto ( )Applicant ( )Owner ( )Contractor. ( )Prefertopickup. Call
) Completed Subdivision
PERMIT #
Phon
(owner, etc.) when ready
Lot
APPL|CANT,S NAME AND ADDBESS Phone-
CONTRACTOR'S NAME AND ADDRESS Phone-
STRUCTURES NOW ON THE PROPERTY
THlsPERl\4lTlSFoR#BEDRoolv]L#PLUl\,!BlNGcoNNEcTloNL
WATER SUPPLY SEWAGE DISPOSAL s.t. #
THlSPRoPERTYlSWlTHlNoNEMlLEoFTHEclTYoF.PLUN/lBlNGBY
I hereby certify that the above statements are true and accurate, and that I have the lollowing legal interest in the property:
-owner
oI record;
-contract
purchaser;
-
potential buyer;
-
realtor or agent. I further certify that (if not the owner) I am authorized to act for the owner of
record. and that said owner is aware and approves of this action. I hereby agree to comply with all applicable Codes relating to this permit.
Fee Paid $-Signature Date
( } NEW ADDRESS () FACILITY PERI\4IT TO TRANSPORTATION DEPT.- () SPECIAL PIV]T. AREA. MIN. ELEVATION:
-
SAN IT toN
Comments:
By
Minimum Septic Tank Capacity (Gallons)
Drainfield Required - Lineal Feet
Maximum Depth
Date
BUILDING
Type of Construction
a"r.""*
Use classification
By:
roup
Date
ire Zone
PLANNING REOUIREIVIENTS SATISFIED. B
ZONE SETBACKS: FRONT
Date Date lssued
SIDE FACING STREET (FROIM C/L) INT. SIDE YARD REAR (FROM P/L)
LANE COUNTY DEPARTMENT OF ENVIRONMENTAL TVIANAGEIVIENT, 125 EAST 8TH AVE., EUGENE, OREGON 974O1
POST THIS PERMIT ON MAIN BUILDING AT SITE
C55.13 BLDG.PERMIT-WHITE; BUILDING-GREEN; PLUMBING-CANARY; SANITATIoN-GoLDENRoD; oFFICEcoPY-wHITE
PHONE:687-4394
Block-
#
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PIot Plan
Job Location (Street, mile post t *195 tq'g SPro,
Subdivision Lot- Block
FOR SANITARIAN'S USE ONLY
COMMENTS:
psvstem Approved fJ System Disapproved fl Needs Correction
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FOR INSTALLER'S USE: Trench Depth
Tank Capaciq /OoO Manufacturer
Measured distance to well fromtankAh 7"1aft*
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3 o-s3 "Filler Depth Below T
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 Management,
Public Service Building, 125 East 8th Avenue, Eugene 97401
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( ) Building Permit /
Acrease or Lot si* /2? X /?7'
Partitioning #- ( )ComPleted( )Pending
A PPLICANT'S NAME AND ADDRESS
fl
INFORMATION SH
(}SiteFeasibilityStudyforSepticTank.Numberofsites
Test holes will be readY
wr itten Directions
o WNER'S NAME AND ADDRESS, if d if ferent f rom aPPlicant's
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,vla il permit or results of site feasibility stud
NTRACTOR'S NAME AND ADDRE yto (14Applicant ( )Owner ( )Contractor
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Contractors 4ll(owner, etc.) when readY
PBOPE RSTRUCTURES NOW ON THE
PROPOSED USE (this Permit)
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WATER SUPPLY
SEWAGE DISPOSAL
L4 u-t*L 71
existing or proposed well, etc. lf public, name of systern)
xisting or proposed septic tank, etc') S'l
Address
PLUMBING BY
4,ROPERTY IS WITHIN ONE MtL
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EOFCITYI )
* OFFICE US E ONLY BELOW THIS LI [\f **+*+t*+tf, *** t++ *t***+rt *t +*
( ) Special Permit Area Minimum Elevation
lnterior Side Yard Rear
-
(FROM PROPERTY LINES}
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1 ) New Address NecessarY
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( ) Facility Permit NecessarY
Front Side Facing Street
(FROM CENTERLINE OF ROAD)SETBACKS:
To: Planning/B ui lding I nspector/Sanitarian/Surveyor
- inis app licant aPPears to have a Prob lem with
Your assi stance will be aPPreciated Permit Processing SectionBy
Response
By
DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
Permit Processing Section
125 East 8th Avenue
687-4394
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