HomeMy WebLinkAboutPermit Building 1978-10-10 (2)s.l. #
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APPLICANT'S NAME AND ADDRESS
Job Location
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Written D irections
B lock
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SITE FEASIBILITY REPORT FOR SUBSURFACE AND ALTERNATIVE SEWAGE DISPOSAL
.ES Gu t LE D. LUGE Phone
Phone
?IT?
OWNER'S NAME AND ADDRESS JA
Mail reportto ( )Applicant ()Owner
\RUCTURES NOW ON THE PROPERTY
TEST HOLES READY
( ) Prefer to pick up. Call (owner, etc.) when ready.
PBOFOSED USE OF PROPERTY-
WATER SUPPLY WITHIN ONE MILE OF THE CITY OF (NO
I hereby certily that the abovo statemema are true and accurate, and that I have the following legal inter€at in the property: _owner ol record;
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contract purdlaser;
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potential buyer;
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realtor or agant. I further cortily that (if not the owner) I am authorizod to act for the owner of
rocord, and that said owner ia aware and approvoi o{ thia action.
Signature CH l -71Date
SITE MEETS STATE STANDARDS E DOES NOT MEET STATE STANDARDS LAND USE COMPLIANCE
I Zoning
t Acreage or Lot Size- (TOTAL)
Partitioning #-( ) Completed( ) Pending
Parcel #--
THIS IS A PRELII\4INARY REPORT WHICH DOES NOT ENSURE THE ISSUANCE OF A FUTURE BUILDING PERMIT, ANY PLANS OR EXPENDI
TURES MADE IN RELIANCE UPON THIS REPORT ARE AT YOUR OWN RISK. IF SITE IS APPROVED, SEE REVERSE SIDE.
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AUTHORIZED SIGNATURE DATE
Division of Water Pollution Control
LANE COUNTY DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
c55-32
AUTHORIZED SIGNATURE
Permit Processing Section
DATE
125 EAST 8TH AVENUE, EUGENE, OREGON 97401 687-4061
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* * . oFFtcE usE oNLy BELOW TH|S L|NE * * *
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OAR Chapter 340, Division 7, Section t2-O2}l6l: 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.)I
LANE COUNTY DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
125 EAST BTH AVENUE, EUGENE, OREGON 97401
PI-ANNING DMSION Curront Zoni
lPending
AVERAGE PROCESSINC
Partltloalng l--
Parccl No.-.-
e ted
P6rtltlonlnq Re qu I red
Othcr r
HATEI POLLUtIOT{ coNTRoL I o! Sttc
IGY Slt. Inrpcctlon(.)
EDS Conrtructlon Tl NGU f, nopatr
Nus&€r of Bedroonat
Comtcrclal,/Industrlal - I o! Employe.!
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CONSTRUCTION PERMITS AND INSPECTION(S€o abova lor I of bedroorrs,/f of employcce)
n !,roblr. HorD.
f] parmancnr
tr Tcmporlry
[-1 Reneyal
Structura
TotaI v!lu.rtIon
_-_- Plmbing fixture3 at
Scacry',tater Conn. At
Subtotr I
{l stotr Surcharg.
Planr Chcck Fcc
Changc ol Occupancy
TOTAL BUILDING PERHIT TEE
t{lnlmun rtructural tbacks l
FroE canterlinc o atroct: Front
FEE
Sq. Ft. valua on I
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Each 3
Proo ln
f] co*ro
PIJBL I C
PUBLIC
t.r lor
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t.ANDS r
tr
L HEALTH
Exter ior Sld6
t lincs: Side-*_ Rear_
lhcet to appllcant f] CurU cut ro appllcant
Address f] Hinimm Elev!tion
Paci Ii ty Permit
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Carh ,Chrcf I Boc'd TOTAT S
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ArFIDAvfi r It thi! pcrmtt la for an agricultural building, I hereby declare thlt thl! bulld 1ng
andvllI be used for agricultural purposelr as aiiowed by zoning and/or the Statc Buildinghor certrfy that thc staLements.nd other infornatlon ru
Code,for no other purpo3., I furt bmlttod onthla applicaeron are true and accurate, and that I have the following legal interart ln theprop€rty: _oiJner of record;con t rac t purchaaer i 68ee;holder of rn Grclurlvc opt lonLo purcharol _drrly .uthoriz eil--t-o act for r peraon u . the fo-floying Iegal lntereat r
e[eII catlon, if I am not-t ; or thdt the omer of record is knowledgeablo o! thiefurthcr.greo comp I
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'F'6-ha hrre coLrnty
hi:--ilwnci.*--t vith
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all o oblc oder relating
HEato thir pernlt.*- q,,t ey' zg AppI icant t a Sr'lnature
THIS IS YOUR RECETPT, AND DOES NOT GM YOU PDRHTSSION TO BUIIB.
rOR INTOru,tATION AIOUT THE PROCRESS T- YO(!R APPLICATION, CALL PNRM1T CONTROL, {]57 (687-IIELP)
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APPLICATI c] IV Offlct Urc Only
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[:l tutr- (:()ru'I.]nir] rrRulr r."i,rr:N/(:oN'tR.^cloR ((:ll(cLl: lrr,r)l -l IRIF[.R T0 pIcK ut,, cAl.LIJL P,(tStXT tlSl: Of I'liol'Ll{TY (rorldrnt lel I tyFc of f {rrl0gi colurclel or lndut rlrt; vtcrnt I "Gc,F re drp f Dpc E P
2, DESCRIBE STRUCTURES NOT, ON THE PROPIiRI'Y. NOIE AN\'SIIiIIC'fURES TO D}, DEHOLIJiIIEI)O rltCl Onr E ,D
ADD'{ESS_____.____
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THIS PROPERT'! (tilts Arll_
FUTURE tLANs :-_ _ &jlA ! -qul A*r_
5. r'Lo]'Irlr Sketclr (a) all roorls
proposed se!ge dlspo
(g) cascmnts (h) dr
or 1n(luitrlrl, shou f
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(b) brrrndarlca of property (c) extsting/proposed bu{ldlnge (d) extatlng/sal areas (c) exrsrtnB/proposed velts (f) extstlng/propoJed arrr""iyi--"alna8eusys, gtrea&e, creeks. auy orher pertrnent feitures. Ir.omicralrcestandrnS elgns, parklng areea. INDICATE DIHENSIONS.
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I'N()l,OSil) l,JA ILR St:l'f t.Y
Il Ir:lHIClT) [r,R:ilsllrt) BY
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BEroRt: YouR AI'Pl.lcA'l loN ()\N 8E PRocEsslrD You Mtrsl rtlNlsh: .__.___8!rll pLor pLANs LEGAL DEscRlpTIoN
(DTxENSIONED)
ldne courty
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,,LAN E COUNTY D EPARTME NT OF ENV I BONMENTAL MANAGE ME NT
125 E/ 'BTH AVENUE, EUGENE, OBEGON . J1 6lE
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