HomeMy WebLinkAboutPermit Building 1974-04-11IANE COl.' JUILDING PERMIT OR MOBITE ' -I.. USE APPTICATION
PERMIT TYPE - BUILDING PERMIT Vs {-z
PR9PERTY ER
LOCATIO E POST OFFIC
ITING
MOBTLE HOME !OSC REG.+r-
a
RESS
tler* e.l/c-
N
PHONE
METES & BOUNDS
ATTACHED
AREA
a
.{
PROPERTY IEGAT DESCRIPTION
TOT_BIOCK_SUBDIV.
TWP RANGE
APPLICANT
NAME
AND
MAITING
ADDRESS
QG\ D
YES
NO
SEC..Z TAX tOT CODE CENSUS TRACT
3-6
DESCRIBE EXISTI STRUCTURES ON PROPERTY IT ANY
t't(;'| -
TEGAI. ACCESS PROPERTY _ ROAD
PROPERTY SI DEPTH
()
FOR MOBILE HOME PERMIT ONLY
Number of Bedrooms Connect to Existing Sewoge Sysrem !or New System R"q. E
STRUCTURES TO BE BUILT THIS PERMIT TYPE CONSTRUCIION t\1q @. t Z-
vAruAIrpN
t11ZT
SQ. FT.# BEDRooMS
I^Yto,rrzr
L t gR>l6E-0
PI.UMBING INSTATTED BYSEWAGE DISPOSAI-
PUBTIC SEPTIC TANK OTHER
FEES WATER SUPPTY
PUBTIC
OWNER
PTANS FURNISHED
OTHER NAME
OTHER YES
FACIIITY PERMIT
NO
BtDG.
WASTE DIS.
PI.UMBING
PLAN REVIEW
PARK TRTR.
PTUMBING FEES
tQ ,'rrr*r,
S DATE
DATE
CASH N
CHECK 2-z
l=Jg-.
-
PUBTIC WATER
CONNsCTION FEE
NECTION FEE
#
d
COUNTY BUILDING & SANITATION SPECIFICAIIONS
DRAIN FIETD REQUIRED
,N. FT.7OO TRENcH wtDTH
OCCUPANCY ZONE REAR Y,
TOTAI.
MIN. SEPTIC TANK CAPACITY
WITH DIST. BOX: GAI.
ilts
OR SQUARE "" ? 6
USE CTASSIIICATION
PUBTIC UTII.. EASEMENTTYPE OF STRUCTURE
BI.DG. SETBACKS _ FT. TROM CTR. OF ROAD RIGHT OF WAY
Form # css-rz
StDffi)eI;-REAR
Dole
SIDE INT
Directions to Find Properly:
NT
7
Dole BLDG. INSP.Dqle PLANNING
_2.
COPY I _ OFFICE
COPY 2 _ JOURNAI.
COPY 3 _ AUDIT
----
2f). -3r/.-
f
LANE C,. -. f BUITDING
BUILDING E MH E
PERMIT OR MOBIT
"lE
USE PERMIT
PERMIT NO.
PROPERTY OWNER MAILING ADDRESS
-rri,
PHONE
it
CONTRACTOR MAITING ADDRESS PHONE
PROPERTY LOCATION _ INCTUDE POST OFFICE
PROPERTY LEGAL DESCRIPTION _ METES, BOUNDS
RANGE SECTION TAX LOT NO-CODE CENSUS TRACT*/1//
EXISTING STRUCTURES ON PROPERTY
't. i
APPT.
NAME
&
MAITING
ADDRESS
TEGAI- ACCESS TO PROPERTY
I , r,,-
PROPERTY SIZE - FT.
wrDTH :Ct DEPTH lnCt AREA
FOR MOBILE HOME PERMITS ONLY
No. of Bedrooms
STRUCTURES TO BE BUILT THIS PERMIT
Connect to Existin
TYPE CONSTRUCTION
m New m
SQ. FT BDRMS VALUATION
I l+grrcr 2 3l 1htx
c
I xspecr t oN 0, K
SEWAGE DISPOSAT PTUMBING INSTALI.ED BY
PUBTIC
BUITDING
WASTE DISPOSAT
PTUMBING
PTAN REVIEW
PARK TRAITER
SEPTIC TANK OTHE OWNER OTHER: NAME
WAIER SUPPTY
PUBUC tr n OTHER
s FEES
10
14
TOTAL
COUNTY BUILDING & SANITATION SPECIFICATIONS
MIN. SEPTIC TANK CAPACITY
WITH DIST. BOX: GAT.
DRAIN FIETD REQUIRED
I.IN. FT TRENCH WIDTH FT OR SQ. FT.
(oOF DRAINS To STREEI
TYPE OF STRUCTURE OCCUPANCY ZONE
,l
PUBTIC UTIT. EASEMENT
BI,DG. SETBACKS FT. FROM CTR
FRONT ' SIDE INT,
OF ROAD RIGHT OF WAY
i
.,
I srDE ExT.
USE CTASSIFICATION
REAR
AUTHORIZED SIGNATURE _ DATE
J
DATE
i
I
BI.DG. PERMIT _ WHITE
OFFICE COPY _ WHIIE
COUNTY TAX _ PINK
PTUMBING _ CANARY
BUILDING _ GREEN
SANITATION _ GOTDENROD
Coll 687-4065 to schedule oll required inspections. All construc-
tion sholl comply with Uniform Building Code, D.E.Q. stondords
IMPORTANT: for subsurfoce sewoge disposol ond county regulotions covering
plumbing. All buildings require o certificote of occuponcy before
being occupied.
(See Detoils on Reverse Side)
oosr THrs PERMTT ON MAIN BrDG. AT SITE)
LANE COUNTY, DEPT. OF ENVIRONMENIAT MANAGEMENT
COURTHOUSE ANNEX,"I3s EAST 6th, EUGENE, OREGON 9740Ironu # c55- t3
l.
B U I LD ING S ITE EV' 'AT ION TJz_R
CENS US
-, _lo
A. r- ICANT
NA./t1E
ADD RES
2
B-3 l)er*
LOT--,e .\'
e.//e-L
(.) Building Permit Appl ication No.
( ) S ite lnspect ion
( ) Pre-Permit Investigation u{PHONE
DATE
L/iNT COUNTY PLANNING DEPART}IENT NOT NO YES NAI1 E Dr\TE
aool icable
Zoning Ordinance Compl iance *Tf--
(zone Rl )2. Subd iv is ion 0rd inance Coilffiance ()
()
()
()
3. Requ i red Access
4. Bu i ld ing S ite (Area, l./idth,
Frontage, Setback)
5. 0ther (see comments)
COHHENTS:
(
() (
() (
() (
() (
BUILDING INSPECTION SECTION
6. Plans Submitted
7. Soil Stability (footings)
B. Flood Pl a in
9. 0ther (see Comments)
NOT NO
sppfiqebte -()
YES
,4-r)
)
NA},IE
d (
()
/-)() ()
CO},1HENTS
SANITATION SECTION
10. Sewage Disposal
ll. Usable Area
12. Water Supply
I l. 0t her (see Comments)
DATE I
3o€^-PurPl€-
NOT NO IYES7
(,
/
N
aool icable*rT-(Zo'a
()
((
t
)
(t
COMii1ENTS
TO APPL ICANT:
\j,'-%r Building Permil / Site lnspection
Can be approved.
Cannot be aPP roved at t h i s t inre a
Quest ions and f urther infornrat ion
s ind icated on i teri, N0 above.
on itenrs I through 5 contact the Lane-
COUNTY PLANN ING DEPARTMENT. Qut's t ions .lnd furtlrer infornrat ion on itenrs
t hrouqh I 3 contact the
l.Jill be held in this o{
I s be i ng retu rned.
your buildinq pernr it appl ic.at ion fee is being returned under separate cur'€F
6
()
()
()
LANF COIIN I Y 1'I I\NN ING OEPARTHENT
115. 5i2af l1 r\vcrlue Iast, Eugerte, 0rttgtrn
1i1;trNE 3lrt-llll I'Xl- 231
IANI. COUNTY I]tIILDING & S/\NITATlON DIVISION
135 S ixt,h Av€rrr-rr: East, Ettqett.,, 0r eqon 9740 I
I'lt0Nl : 342-t1la tXT' ql I
97tro i
M55-
DATE
Buildi dlld 5anlta ion Divi';ion.
r/Ou Carl Ie 5O VC t lre p rob lems ndi cat (:d.
Dote Pe)frit-No.4Bi-Ztt
CURB CUT
PERMIT
IN THE BOARD OF COUNTY COMMISSIONERS OF LANE COUNTY
WHEREAS, the ottoched opplicotion hos been fully considered by the Boord of County Com-
missioners of Lone County, ond it is the opinion ond Iudgment of the Boord thot the soid opplicotion
should be gronted, ond thot o permit should be issued, now, fherefore, it is hereby.
ORDERED, thot o permit be ond is hereby issued to Jacx KepsaRr
l59o Snxxr Sour il for plocing, building
or constructing the following focility'
Venn OT
upon the right-of-woy of County Rood No.Mile Post
in strict conformity to the exhibits ottoched hereto, ond subiect to oll terms, conditions, ogreements,
sfipulotions ond provisions contoined in the opplicotion ond permit, the Rules ond Regulotions Gov-
erning Focilities to be Permitted upon County Rood Rights-of-Woy, os set forth by the Lone Mon-
uol 50.19O(.2) any omendments thereto, ond ony other opplicoble regulotions, low or ordinonce.
Speciol Provisions:
L Drivewoy will be constructed in occordonce with the ottoched drivewoy opprooch specifico-
tions (Drowing M98-50).
2. Permittee will be responsible for the immediote removol of oll mud, dirt ond debris from the
roodwoy ond right of woy coused by his operotion, leoving the roodwoyond oreo in o neot,
occeptoble condition.
This permit is revocoble ot ony time, ond will be strictly odhered to ond no work other thon
thot specificolly mentioned obove is hereby outhorized.
This permit sholl be void unless the work herein contemploted sholl hove been completed be-
fore 19-'. Expires 19__.
lnspected ond Approved Approved by Boord of County Commissioners
By
Dote
By
WHITE _ OFFICE FIIE
GREEN _ RESIDENT ENGINEER
PINK _ PERMITTEE
BtUE - ROAD SUPERVISOR
ORANGE - BUII.DING & SANITATION DEPT
YETLOW _ REAL ESTATE
Director of Public Works
c98-1 9
\
--
L/
E
Dc+e Permit No.
CURB CUT
PERMIT
IN THE BOARD OF COUNTY COMMISSIONERS OF LANE COUNTY
WHEREAS, the ottoched opplicotion hos been fully considered by the Boord of County Com-
missioners of Lone c;r;t, ond'ii it th" oplnion ond iujgment of the-Boord thot the soid opplicotion
,f,.rfJ Le gronted, ond ihot o permit should be issued, now, iherefore, it is hereby'
ORDERED, thot o permit be ond is hereby issued to
for plocing, building
or constructing the following focility,
upon the right-of-woy of County Rood No Mile Post
in strict conformity to the exhibits ottoched hereto, ond subi ect to oll terms, conditions, ogreements,
sfipulotions ond provi sions contoined in the oPPlicotio n ond permit,
ghts-of-Woy,
the Rules ond Regulotions Gov-
erning Focilities to be Permitted upon Co Rood Ri os set forth by the Lone Mqn-
ony other opplicoble regulotions, low or ordinonce.
unty
onduol 50..l90(2) ony omendmenls thereto,
Speciol Provisions:
I. Drivewoy witl be constructed in occordonce with the ottoched drivewoy qPProoch specifico-
tions (Drowing M98-50).
2. permittee will be responsible for the immediote removol of oll mud, dirt ond debris from the
roodwoy ond right of woy coused by his operotion, leoving the roodwoyond oreo in o neot,
occeptoble condition.
This permit is revocoble ot ony time, ond will be strictly odhered to ond no work other thon
thot specificolly mentioned obove is hereby outhorized.
This permit sholl be void unless the work herein contemploted sholl hove been completed be-
fore 19_.Expires I9_.
lnspected ond Approved by Boord of County Commissioners
By
Dote
WHITE _ OFFICE FIIE
GREEN _ RESIDENT ENGINEER
PINK - PER t{lTfEE
BI.UE _SUPERVISOR
ORA BUII.DING & SANITATION DEPT
YEI.- REAL ESTATE
Director of Public Works
c98-7 9
Dote \-z-t\
ORDERED, thot o permit be ond is hereby issued to
PERMIT
IN THE BOARD OF COUNTY COMMISSIONERS OF LANE COUNTY
WHEREAS, the ottoched opplicotion hos been fully conside_red !y the Boord of County Com-
missioners of Lone cornty, ond'it is the opinion ond iudgment of the-Boord thot the.soid opplicotion
rl,"rfa be gronted, ond ihot o permit should be issued, now, therefore, it is hereby'
Permit No.
tr8r-Th
CURB CUT
Jlcr KePnnnr
15W S t'Att Sr. SPn t rucr t Euo, 0Recor't for plocing, building
or constructing the following focility'
VEnr DEt-t-E Sueo lv ls loN Lor 1O
Dweut t Ne
, B-3
upo n the right-of-woy of County Rood No.Mile Post
in strict conformity to the exhibits ottoched hereto, ond to oll terms, conditions, ogreements,subiect
ond pesfipulotions ond pro visions contoined in the opplicotion rmit, the Rules ond Regulotions Gov-
itted upon Co Rood Rights-of-Woy , os set forth by the Lone Mon-be Perm unty
ond
erning Focilities to
uol 50.190(2) ony
Speciol Provisions:
omendments thereto,ony other opplicoble regulotions, low or ordinonce.
Drivewoy will be constructed in occordonce with the ottoched drivewoy oPProoch specifico-
tions (Drowing M98-50).
permittee will be responsible for the immediote removol of oll mud, dirt ond debris from the
roodwoy ond right of woy coused by his operotion, leoving the roqdwoyond oreo in o neot,
occeptoble condition.
SIOgWEUX WILL BE CONSTRUCTED IN. ACCORDANCE WITH THE ATTACHED SIDEVJALK
spEc tF I cAT toNS AND oRAw lr.re pB-\9. TnE STANDARD cuRB rYPE SHALL BE
CONSTRUCTED UNLESS OTHERW I SE SPEC I F I ED'
This permit is revocoble ot ony time, ond will be strictly odhered to ond no work other thon
thot specificolly mentioned obove is hereby oulhorized.
This permit sholl be void unless the work herein contemploted sholl hove been completed be-
fore Jur-v JO 7h\9 '- . Expires l9__.
lnspected ond Approved Approved by Boord of County Commissioners
By
By
2
3
WHITE - OFFICE FITE
GREEN - RESIDENT ENGINEER
PINK _ PERMITTEE
BtUE _ ROAD SUPERVISOR
ORANGE _ BUITDING & SANITATION DEPT
YEI.TOW _ REAI. ESTATE
Direclor of Public Works
c98-7 9
Dote
-
,/-"r-)-,42
T
Dote Permit No
CURB CUT
PERMIT
IN THE BOARD OF COUNTY COMMISSIONERS OF IANE COUNTY
WHEREAS, the ottoched opplicotion hos been fully considered by the Boord of County Com-
missioners of Lone County, ond it is the opinion ond iudgment of the Boord thot the soid opplicotion
should be gronted, ond thot o permit should be issued, now, therefore, it is hereby.
ORDERED, thot o permit be ond is hereby issued to
for plocing, building
or constructing the following focility'
2
upon the right-of-woy of County Rood No.Mile Post
in stri ct conformity to the exhibits ottoched hereto, ond subiect to o
ond permit
hts-of-Woy,
ll terms, conditions, ogreements,
sfipulotions ond provisions contoin ed in the opplicotion , the Rules ond Regulotions Gov-
erning Focilities to
uol 50.I90(2) ony
Speciol Provisions:
be Permitted u pon County Rood Rig os set forth by the Lone Mon-
omendments thereto, ond ony othe r opplicoble regulotions, low or ordinonce.
Drivewoy will be constructed in occordqnce with the ottoched drivewoy oPProoch specifico-
tions (Drowing M98-50).
Permittee will be responsible for the immediote removol of oll mud, dirt ond debris from the
roodwoy ond right of woy coused by his operotion, leoving the roodwoyond oreo in o neot,
occeptoble condition.
-rl-?(
/
/
This permit is revocoble ot ony time, ond will be strictly odhered to ond no work other thon
thot specificolly mentioned obove is hereby outhorized.
This permit sholl be void unless the work herein contemploted sholl hove been completed be-
fore 19-.. Expires r 9_.
lnspected ond Approved Approved by Boord of County Commissioners
By
Dote
By
fr
WHITE _ OFFICE FITE
GREEN - RESIDENT ENGINEER
PINK _ PERMITTEE
BI.UE - ROAD SUPERVISOR
ORANGE_EUITDING & SANITATION DEPT
YETLOW - REAI ESTATE
Direclor of Public Works
c98-7 9
I
a
LANE COU].. / BUITDING PERMIT OR MOBILE h-.dE UsE PERMIT
MH ;r
MAII-ING ADDRESS
PERMIT NO hBUILDING
PROP OWNER
PHONE
PHONE
CONTRACTOR MAITING ADDRESS
PROPERTY I.OCATION _ INCI-UDE POSI OFFICE
tl{q Yem Orrvt
PROPERTY TEGAI. DESCRIPTION -METES, BOUNDS
SECTION TAX LOT NO.CODE CENSUS TRACTRANG E
l?o3 Ol9-Ol
EXISTING STRUCTURES ON PROPERTY
APPt.
NAME
&
MAITING
ADDRESS
TEGAT ACCESS TO PROPERTY \
PROPERTY SIZE _ FT.
WIDTH DEPTH - AREA
FOR MOBILE HOME PERMITS ONLY
Connect to Existing Sewoge System f]New System INo. of Bedrooms
STRUCTURES TO BE BUILT THIS PERMIT TYPE CONSTRUCTION sQ. FT. # BDRMS VALUATION
tr
GrtraE, Atl, c s\ --\ i I
SEWAGE DISPOSAT PLUMBING INSTATTED BY
OWNER OTHER: NAME
PU BLIC
BUII.DING
WASTE DISPOSAL
PTUMBING
PLAN REVIEW
PARK TRAII.ER
SEPTIC TANK
F EES WATER SUPPTY
PUBUC n tr OTHER$-\ - \
TOTAI
COUNTY BUILDING & SANITATION SPECIFICA TIONS
MIN. SEPTIC TANK CAPACITY
WITH DIST. BOX: GAL'
DRAIN FIETD REQUIRED
TIN, FT TRENCH WIDTH FT OR SQ. FT.
I\t \
I
TYPE OF STRUCTURE OCCUPANCY ZONE PUBI.IC UTIT. EASEMENT
BLDG. SETBACKS.- FT. FROM CTR. OF ROAD RIGHT OF WAY USE CTASSIFICATION
FRONT SIDE INT SIDE EXT REAR
AUTHORIZED SIGNATURE - DATE DATE
J. Sxoot Ltr*?4 r
BI.DG. PERMIT _ WHITE
OFFICE COPY - WHITE
COUNTY TAX _ PINK
P[UMBING - CANARY
BUITDING _ GREEN
SANITATION _ GOLDENROD
Coll 687-4065 to schedule oll required inspections. All construc-
tion sholl comply with Uniform Building Code, D.E.Q. stondords
IMPORTANT: for subsurfoce sewoge disposol ond county regulotions covering
plumbing. All buildings require o cerlificole of occuponcy before
being occupied.
(See Detqils on Reverse Side)
(posr rHrs PERMTT oN MAIN BLDG. AT SITE)
LANE COUNTY, DEPT. OF ENYIRONMENTAT MANAGEMENT
COURIHOUSE ANNEX, I35 EAST 6Th, EUGENE, OREGON 9740I
-
OTHEREn
,S I TE I NSPECT ION
Ap paov r o
Rruanxs
//DrsAppRovEoDDare I ruspecton
FOUNDATION I NSPE t0N
AppRoveo D r sappnoveD r5':?(DarE I Nsp C TOR
Rrurnx s
o
FRAMING INSPECTION
AppRoveo n Drsrppnoveo
Re t{anx s
oorrd'l1- ?/I xspEcro
')frV '-2
LATH OR SHEETROCK INSPECTION
Ap pnov r o
RExa ax s
DrsappRovEo [7 Dar e -,?I Nsprcton G,/
FINAL INSPECTION
Ap pnov e o
Rruanx s
D t sappRovto fr-P,'l rtDrr e l nspec c,/,
CERTIFICATE OF OCCUPANCY
RraoY ro lssue
REuaRx s
Nor Reaov ro I ssur Dare I Nsprcron
16,5"7{ //r/{*'/t-p'"v*1g<
7
IANE t-.- JN. l/ BUIIDING PERMIT OR MOBI H../IE
BUILDING E MH tr
USE PERMII
PERMIT NO.
PROPERTY OWNER MAITING ADDRESS PHONE
CONTRACTOR MAILING ADDRESS PHONE
PROPERTY TOCATION _ INCTUDE POST OFFICE
PROPERTY I.EGAI. DESCRIPTION - METES, BOUNDS
RANG E SECTION TAX LOT NO CODE CENSUS TRACT
EXISTING STRUCTURES ON PROPERTY
APPT.
NAME
&
MAITING
ADDRESS
LEGAL ACCESS TO PROPERTY
PROPERTY SIZE _ FT.
WIDTH DEPTH AREA
FOR MOBILE HOME PERMITS ONLY
No. of Bedrooms Connect to Existing Sewoge System I New System I
STRUCTURES TO BE BUILT THIS PERMIT TYPE CONSTRUCTION sq. FT. # BDRMS VALUATION
SEWAGE DISPOSAT
PUBUC tr SEPTIC TANK !OTHERTI
PLUMBING INSTATTED BY
OWNER n OTHER: NAME
BUITDING
WASTE DISPOSAI
PTUMBING
PTAN REVIEW
PARK TRAIIER
TOTAT
FEES WATER SUPPTY
PUBUC !tr OTHER
$----
COUNTY BUILDING & SANITATION SPECIFICATIONS
MIN. SEPTIC TANK CAPACITY
WITH DIST. BOX: GAt.
DRAIN FIELD REQUIRED
TIN. FT TRENCH WIDTH FT OR SQ. FT.
TYPE OF STRUCTURE OCCUPANCY ZONE PUBI.IC UTIt. EASEMENT
BI.DG. SETBACKS FT. FROM CTR. OF ROAD RIGHT OF WAY
FRONT SIOE INT. SIDE EXT.
USE CLASSIFICATION
REAR
AUTHORIZED SIGNATURE - DATE DATE
BTDG. PERMIT _ WHITE
OFFICE COPY _ WHITE
COUNTY TAX - PINK
PTUMBING _ CANARY
BUITDING - GREEN
SANITATION _ GOTDENROD
Coll 687-4065 to schedule oll required inspeclions. All construc-
tion sholl comply with Uniform Building Code, D.E.Q. stondords
II,IPORTANT: for subsurfoce sewoge disposol ond counly regulotions covering
plumbing. All buildings require q certificote of occuponcy before
being occupied.
(See Detoils on Reverse Side)
(posT THrs pERMtT ON MAIN BIDG. AT S|TE)
IANE COUNIY, DEPT. OF ENVIRONMENTAI MANAGEMENT
COURTHOUSE ANNEX, I35 EAST 6th, EUGENE, OREGON 97,10Ironu Jf c55- 13
SLAB FLOOR
PLUMB ING GROUND^/ORK
Ap pRov e o
Relt rnx s
DrsappRovro Dare I rspecron
GAS PIPING GROUND/ORK
AP PRov E D
ReuaRx s
DrsappRoveD D DATE I ruspecron
ROUGH PLUMBING
AppRoveo N Drsappnovro D ootr,L!/-_k
ReuaRxs
lrspec
ROUGH GAS PIPING
Appnoveo D DrsAPpRovEo D
Reurnx s
Dar E I rusprcton
FINAL PLUMBING
App nov r o
ReuaRxs
&D r saepRovro D oorrfu lrsprc
F I NAL GAS
Ap pnov e o
Rruanxs
PIPING
D r sappRoveo Dar e I ruspecron
CERTIFICATE OF OCCUPANCY
Reaov ro lssur
RrulRx s
Nor Reaov ro lssuE Dare I NSPEcToR
comprete top 0",.-a?'flll r;'1ff#f::'$i1ff.*[u.l'"oo,es with appr iI NSTALLER:
No. L v
c
P Rr,1 NO
v 7o s.H4 u
ts Baths Bas
es
ater u
Publ ic v
0ther-L i st
Ft. f rorn wel I Steel
lns
Concrete K No. Compartments Gal . Capaci ty
e sPosa e
Di stribution Box: Yes No
t er str ut On-yPe
eet rom
ll oundat i on
ot ne
Front Side
ons:
L th l',idth
NAHE
HAILING
ADORESS
Leng th s-Ft.
4 6
0
r
Ol.,
it tn
er
Ti leu,idt
r
Lines
tw
I>lot PIan see instructions
0ate Si nat u re
TORY C ON
For Sanitarian Use Only: Dat
tn accordance with 1973 Oregon Laws Chapter 835, Section 214 tnis certificate is
as evidence of satisfactory completion of a subsurface sewage disposal system at
to""ffiopproved:
System lnstal lation conforms to current standards
f-t Oisapproved: Ooes not conform to current standards
Remarks:
rs
the ab ove
d an
COUNTY
c55-11
STATE OF OREGON DEPARTHENT OF ENVIRONHENTAL QUALITY
9na ure
tr