HomeMy WebLinkAboutPermit Septic Tank 1990-05-16?
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Permit No.z z /f'-l2f MUST BE IN BLACK INK
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Job Location (Street Address)
Supdivision/Partition *Parcel- Lot Block
DETAIL SYSTEM PLOT AS CON UCTED
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FOR INSTALLER'S USE: Trench Depth
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VIPINITY MAP €-2 -?a
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USE BLACK INK ONLY
I\r Tank Capacity Manufacturer
and Mercury Float Switch (Mfg. and No.)
Gravel
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(Model No.)- PumP
have been installed with this sewage installation
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//o*rro Depth Below Tile c"
Measured Distance from Well to Tank
COMPLETE THE FOLLOWING IF A PUMP WAS USED ON THIS INSTALLATION
I (installer's name)certify that a (Mfg )
Signature Date
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FOR SAN
COMMEN
ITARIAN'S U sf oNLY:Approved .- tr D Correction
m rrected Date
DateSystem Capacity gal./day Signature
INSTALLATION RECORD & CERTIFICATE OF SATISFA TORY COMPLETION When by the County Sanitarian, this certificate is evi-
dence as per ORS 454.665 of satisfactory completion of a subsurface sewage disposal system at the above location.
To requesl inspection, return all three (3) copies of this form to: Lane County Environmental Health Services, located in the basement of the
Public Service Building, 125 E. 8th Avenue, Eugene, OR 97401.
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From Drainfield - Total Length of Lines
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