HomeMy WebLinkAboutPermit Septic Tank 1993-9-14
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VICINITY MAP
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d? MUST ,eE IN BLACK INK 101m c55'11
Permit No. 'J ,) <(0 - 'i J Twnshp. (E Range 0 ~Section (i) 2-. J. !'5rax Lot (,., cro
Standard System ':xl Alternative System..:.8-(Spe~ify-Tjpe)_/,'_ '. . - - _"7
Job Location (Street Address) L I 7 j / ..l,....FAA _ JL {., J'!J' 1 ~~.L:i'/ .J
SupdivisionlPartition # '_ Parcel ~ L-6t _41/ Block
DETAIL SYSTEM PLOT PLAN AS CONSTRUCTED.
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USE BLACK INK .ONLY. .
FOR INSTALLER'S USE: Trench Depih 3D U Gravel Depth Below Tile (" ,( -.
Tank Capacity t'ltlsh.iy 'Tn,,/: Manufact~rer '! vd.. '''Hv '"
Measured Distance from Well to Tank C,!.j l..4,b: From Drainfield _ Total Length of Lines _1'10 I
COMPLETE THE FOLLOWING IF A PUM'P WAS USED ON THIS INSTALLATION: .
I (installer's name) certify that a IMfg.) .(Model No.) Pump
and Mercury Float Switc~g. an~ No.) have been installed with this sewag~. ~nstallation.
Slgnatur" ~ 1r'fi- . _ Date .'0///4/"13
FOR SANITARIAN'S USE ONLY: .
COMMENTS:
. System Approved
o System Disapproved --0 Needs Correction
. o".,s. y,stem .corrected Date.
System Capacity ~<"""('). gaUday Signature ...0. ~_ Date '1 ~/ tb - ...., -<
INSTALLATION RECORD & CERTIFICATE OF SATISFACTORY COMPLETION When Sigrid"by the County Sanitarian. this certificate is eVi~
dence as per OAS 454.665 of satisfactory completion of a subsurface sewage disposal system at the above location.
To request inspection, return alllhree (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. 0'3 97401.