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ORYFor Sanitarian Use Only:Date:7-2-7Lln accordance with 1973 oregon Laws Chapter 835, Section 214 this certificate is issuedas evidence of satisfactory completion of a subsurface sevrage disposal system at the above
I ocat i on.
E npptoved: System lnstallation conforms to current standardsI I Disapproved: Does not conform to current standards
Remarks:
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STATE OF OREGON DEPARTMENT OF ENVIRONMENTAL QUALITY
gnat ure
ts
-\
n Owner
LANE COUNTY PERMIT FOR PERIVIIT NO
CONSTRUCTION [ ] IVIOBILE HOME [ ] PLAN REVIEW t ] CHANGE OF OCCUPANCY [ ]
NA I\1E ADD R ESS CITY ZIP CODE PHONE
u Contractor
NAIVIE ADD R ESS CITY ZIP CODE PHONE
O.S. Reg, *
Tw
Subdivision- Lot
Access to Property (Road Name)
Range- Section-Tax Lot=--..- Code- Census Tract_
B lock Acreage Width
Depth
Existing Structures on Property:
Directions to Property - Address
STRUCTURE (# BEDROOIVIS)SO. FT VALUATION
SEWAGE D ISPOSAL PLUIVIBING INSTALLED BY:
OWNER[] OTHER[] NAIVIPUBLIC[] SEPTICTANK tl orHER[]tr
BUILDING
PLUIVIB ING
3% SURCHARGE-
IVIOB ILE HOIVIE
WASTE D ISPOSA L
PLAN REVIEW
TOTAL
WATER SUPPLY: PROPOSED t ]
EXISTING I ]
PUB LIC
COTVIIVIUNITY . NATVIE
PR IVATE WELL
OTHER .SPECIFY
CONSTRUCTION PERMITS & INSPECTIONS AND WATER POLLUTION CONTROL SPECIFICATIONS
IVIIN. SEPTIC TANK CAPACITY
GALS IVIIN. DRAINFIELD LIN. FT IVIAX. TRENCH DEPTH I NCH ES
STAY 1OO' FROIVI ALL WELLS
TYPE OF CONSTRUCTION- GROUP FIRE ZON USE CLASSIFE
SETBACKS FT. FROI\4 CTR. OF rAN
FRONT SIDE EXT
FT. FROIVI PROP. LINE
SIDE INT REAR ZONE
AUTHORIZED SIGNATURES
lsl
ISSUANCE DATE
BLDG. PEFMIT - WHITE
OFFICE COPY _ WHITE
COUNTY TAX _ PINK
PLUN4BING - CANARY
BUILDING - GBEEN
SANITATION - GOLDENROD
IMPORTANT
Call 687-4065 to schedule all required construction inspections. Call 687-4061 to schedule all required
septic system inspections. All construction shall comply with the State Buidling Code, D.E.Q. standards
for subsurface sewage disposal and the State Plumbing Code. All buildings require a certificate of
occupancy before being occupied.
(See Details on Reverse Side)
(POST THlS PERI\4IT ON MAIN BLDG. AT S!TE)
LANE COUNTY, DEPT, OF ENVIBONMENTAL MANAGEMENT
COUFTHOUSE ANNEX, 135 EAST 6th, EUGENE, OREGON 97401
L,U PERMTT + ,/?"lS" 7O\
NOTE: NO PERMIT WILL BE ISSIIED T]NTIL THIS APPLICATION HAS BEEN APPROVED
CONSTRUCTION MOBILE HOIM
APPLICATION FOR
PLAN REVIEW CHAi.IGE OF OCCI'PANCY
a,t,5'
re ,/-8)OWNER
CONTRACTOR
Name ess Ci zlp
rvp. 18 n"r,e"-J-sectionJ, J rax
Clty zLp
tSoa,,*nd-coa"-!9:-Q2--census Tract
Name Address
Lot
Phone
o. s. REG. /l
ACcESs ro PRoPERTY tno.a u"r"lSocc*h dY S*red
Exiscing Structures on Property
Property Locatlon - Address/Directions +l
Below Office Use
SEWAGE
Slt.e Inspec tlon /i Exlsting Sewage Dls
Publlc
WATER SI]PPLY:
Well
FEES:
System B or New SYstem Required
*
Name of Coomunity or Publlc System
Subdlvls
Bldg.
P1rlnblng
3% Surcharge
Waste Dlsp.
Plan Revlew
Moblle Hone
B1o ck____Property
Sq. Ft.
Other
wld th_Depth_
Valuationedrooms
-
erl'Spring
3{, aa
-PGoo
Name
Fixtures
Fire
Sewage
CoIInection
PI.ANS FURNISHED
YES l2<J$o
Signature of APPllcant
Fee Recelved BY
Water
Connection
FACILIfi PERMIT
YES ELuo
Date:TOTAL
type of Construction
Maximum
ed by Owner
FEES:
Bldg Setbacks - frou Center of Road Right of way:
Rear ZoneSlde Int.Side Exterior
DATE:DATE:BUILDING
PIANNING:
c55-12 LAT{E COT]NTY DEPART}'IENT E}WI RONMEN TAL MANAGB{EN T
DATE:
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