HomeMy WebLinkAboutPermit Demolition 1978-10-05s.t. #
TRS, T L Jdb Location
Written Directions
Lot ,' Block
SITE FEASIBILITY REPORT FOR SUBSURFACE AND ALTERNATIVE SEWAGE DISPOSAL
APPLICANT'S NAME AND ADDRESS
Subdivision:
Phone
OWNER'S NAME AND ADDRESS Phone
Mail reportto ()Applicant ()Owner
OTRUCTURES NOW ON THE PROPERTY
( ) Prefer to pick up. Call (owner, etc.) when ready.
oo.rDosED r-!sE oE pRCTpERTY
WATER SUPPLY WITHIN E MILE OF THE CITY OF (NO
I hereby certify that the above statements are true and accurate, and that I
contrae;t purchaser; potential buyer; realtor or agent. I
have lowing legal interest in the property
-owner
of record;
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
TEST HOLES READY-
* * * OFFICE USE ONLY BELOW THIS LINE * * {
Signature -
Date
SITE: E MEETS STATE STANDARDS E DOES NOT IVIEET STATE STANDARDS
i .; ,.. , ,rr
LAND USE COIVIPLIANCE
Zoning
Acreage or Lot Size (TOTAL)
Partitioning #-( ) Completed( ) Pending
Parcel #-
THtS tS A pRELtMtNARy REPORT WHTCH DOES NOT ENSURE THE TSSUANCE OF A FUTIJRE BUlLqtlc P-!!lrlT ANY PLANS OR EXPENDI-
iunEs nanoe tN REL|ANCE upoN THts BEpoRT ABE AT YouR owN RtsK. lF slrE ls APPBoVED, sEE REVERSE slDE.
AUTHOBIZED SIGNATURE DATE
Division of Water Pollution Control
LANE COUNTY DEPARTMENT OF ENVIRONT\4ENTAL MANAGEMENT
c55-32
AUTHORIZED SIGNATURE
Permit Processing Section
DATE
125 EAST 8TH AVENUE, EUGENE, OREGON 97401 687-4061
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OAR Chapter 340, Division 7, Section 72-02016): This report shall remain in effect until issuance of a
permit to construct, unless in the meantime conditions on this or adjacent properties have been altered in
any manner which would prohibit issuance of a permit, in which case this evaluation report shall be con-
sidered null and void. Technical rule changes will not invalidate any evaluation report issued pursuant to
this section.
Before construction is started bring this form to the Department of Environmental Management and apply
for a building permit. Exact specifications for the sewage disposal system will appear on the permit.
lf the property is only a portion of a tax lot, a partitioning or subdivision must be approved before the
permit will be issued.
Only persons having a valid license issued by the Department of Environmental Ouality under ORS 454.695
to install subsurface sewage disposal systems or an owner or contract purchaser or his regular employees
may install subsurface sewage disposal systems. A certificate of satisfactory completion will not be issued
if persons other than the above perform the installation.)
LANE COUNTY / 'ARTMENT OF ENVIRONMENTAL M ^ \AGEMENT
125 EAST BTH AVENUE, EUGENE, OREGON 974-.
PIANNING DIVISION CuTrent Zoni
Partltlonlng l_ f]Pending
Parccl No.
AVERAGE PROCESSING
eted
on
Other r
nATEA POLLUTION CONTROL I of St
llsv Slt. InBp€ctlon(8)
dtu\U,V\tr
Htsots,>I}l
t)c
t0o.H'
HoHo
6DS Conatructlon n NGu
Nunb€r of Bedroomar
Connrarclal,/Industr laI -
Other
I nepatr
I ol Employee!_
I
tl
D
CONSTRUCTION PERHITS AND INSPECTION(See above for I of bedroons/f of employeea)
t] i.tobttG nolao g
f] permanent
A Temporary
tlStructura
Cc.h_ Ch.cL
ArPIDAVIT: lluill be used forfor no o
Renerral
le perml
agr lcu I t
th ti8
Total v!Iuation s
, Plumbing fixtures at t.
_ Sewerftater Conn. at t
Sg. Ft. valuatlon
Subtota
TOTI\L LDING PERHIT PEE
s ldo
Rear
$
E
6ltt
oE
tlt State SurchargG
Plans Check Pee
Change o( Occupancy
linlrnun ltructural Betbacks:
Froro centerlinc ol etreet: Front
Exter
Froo lntcrlor lot lines; Side
f[ Conno'l plans sheet to appll I CurU cut to appllcant
PIJBLIC I-ANDS. tr AddresE tr Minlmum Elevation
PUBLIC t{oRKS - paciliry perrnit
EMvIRONHENTAL HEALTH
\\d TOTAI. S
thi8 app
ther purposeIi-cation are
ura I purposes as alloued by zoning and,/or the State Building Code,
an agricultural buil.dling, I hereby declare that thls butld lng
andI further certify that the statemcnts and other information submltted ontrue and accurate, and that I have the followi ng legal intereat in theproperty:orrner of recordi con lract purchaser;lessee;holdertdflouing of an excluclve optlonto purchase; _duly authorizetfto act for a person wE6-has the legal interests
tPp ca
or that the owrler of record is knowledgeable of this
am e ouner further agr y with al.l !ab codee relating
bre coLrnty
to this Dernit.
Drt. d/ zt / zA----7----7-Applic.nt's Signature
?EIS IS YOUR RECEIPT, AND DOES NOT GIVE YOU PERIITISSION TO BUILD.
IOR INFORMATION AAOUT THE PROGRESS OF YOUR APPLICATION, CALL PERMIT CONTROL, 687-,t35? (687-HELP)
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Address
Minimum Elevation
6l!'
-
s
s
q
q\cf-
sr# 78-
LOCATION: TWP.
SITE EVAIUATION I.IORKSHEET
SECTION /7
PROPOSED USE:
/7 RANGE CJ TAX LOT #
ZONING:RA Ril
SIZE OF PROPERTY:
WATER SUPPLY:COMMUNITY PUBLIG
SUBDIVISION/PARTITION 6/eilon /c.*s
IF SITE MEETS STANDARDS FILL OUT:
Type of structure and approximate sewage flow:
Itulti-family
ConrmerciaI cPd
A.I.IOUNT US$LE AREA:4l)
INDIVIDUAL
LOT / / BLOCK
/0ooO s?fl 't
PARCEL
Single Family
IndustriaI
gpdi/U,,,
8Pd
sPd
tso
cpd
Ins t.itutional
MINIMUM DESIGN REQUIREMENTS:
Length of disposal trench required L{o il of 75 ln.o/ Pl It5O gaL.
Distribution Method:
Curtain drain required:
Oche r :
Equal El SeriaI
NoYes ^E}.
SPECIAL SITE CONSIDERATIONS OR VARIAI.ICE OPTIONS OR OTHER ALTERNATIVES:
DATE OF EVALUATION:tr/",/ 74
NA}18:
DQC
bngl"lc
c7 4-126
3tJo^ 7{
tr
SI# 7 7/&
PREDICTED WATER
Predic ted
Observed
Date
in.
in.
SATURATED ZONE
Predic ce d
se rved
at.e
strictive Layer _inImpervious Layer in
t.tling
SLOPE
1n
1n
SITE DOES DOES NOT MEET MINII'II.JM STANDARDS.
ADMINI RATIVE RULES REQUIRE A I.IINIMUM DEPTH OF:
36 inches t.o an impermeable layer
30 inches to a restrictive layer
60 inches to a permanent water Eable
24 inches to a t,emporarily perched water table
OTHER REASONS FOR DENIAL
1n
ON YOUR PROPERTY THtr DEPTH
I.IAS:
inches
inches
inches
inches
iI TEST }tOLE iI 2 TEST HOLE
PERCHED WATER PROFILE PROFILE
Pre dic te d
Obse rved
Datc
1n
1n
Inch lnch
SATURATED ZONE
t2
24
36
48
60
72
24
36
48
60
Predicted
Obse rved
Dat.e
.1n
IN %
4rr^
,l
/o
to"
Restrictive Layerza< in
lmpervious Laye t ztn=4-t in
Mott ling -zra-rY 80 in
SLOPE o/
PLOT PLAN:
SEream
...4-4,.-b
Drainage or
1;ond
1... latax..lrt,
Road
Test uole @
\ % SloPe
Cut Bank
./ t r17-
l"c t rctl
x-x
S* ?L+ M^p Aor //
x
tr
tr
T
tr
Il..rr Print - Xet rm Applltatlon to
l...If lonl.t Lhon Cool.letr.d
APPL rudl€LE/J T arac -
ADDTESS _€1
ctD{tt (Ir DITTEnENT)
ADtrirss
APpolrtxx-lrt nrtt.
APPLICATIc) N8y elaaLEJ H. 6u4
Offlc€ Urc Onlt
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ADD'{ES S
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,_ -. --coNrRAC',r()k'c ()Rf . STATE LtCl.tNsE
i.}.TII} PIlRHIT TO rR/(;oN'rRACI0R (clRcLr oHrlI I pRrrER T0 ptcK up. c^l.L
E ol- PR.IERTY (rcrrd.ntrali typa of romtogl co@rclrl or rndutrreli vacent: ctc
dti2 7 OpZ
2, DEscRluE STRUCTURES NolJ oN TllE PR0PIiRt'I. NI)TE AN't'stRUctuREs To Bl. DLlt()LIslEt)SlEl ---T:a--- -?-'E Er?zat-t.ttr'E>
n*r,..-'f 4?'b1!t dt ttp 6G,g,Aolt)
f]lrutt coro'
I, PRESEHT US
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apE
1lrts PRoPER'l.Y
5, PLoT ti-Ax Ske.tch (a) all roads (b) borndarlea of property
proposed serte dl6posel areag (c) exlst tng/pro(8) .o!('nnti (h) dralnagcvaya, atrclos, creckr
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o tr1al,ehou frcestand!ng e!gns, parklng
' (c) extstlng/proposed bulldlnts (d) exlstln8/,poeed uells (f) erl.t1ng/propoced drlvee.y!
, rny othcr p.rtrnent fetturea. If comrrclalrrers, INDICATE DIHENSIoNS.,r lndus
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sllt tNlil,ECTtON T[:St. lt()LLS REAny (DATt:)
I'N()POSi.t) lJ,\ rt.R st't'H.Y
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lJtlt._ sl'RINC _ SI.RI:AH LAKE t,wlo* lrA r7CEyTa :
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EEfORt. YoUR Alrl.lL\] lo:t ()\N 8E PROCT.SSLD YoU HI'ST !'l.tR\ISH: ._____-8\xl I pLOT rL XS LEcltL DESCRIPTION
(DI MENS ION[:D)
ldne carty
A*61._{/_f_ _-D,\Tf:7
LANE COUNTY DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
125 IT 8TH AVENUE, EUGENE, OREGOI - "401
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