HomeMy WebLinkAboutPermit Building 1975-2-27
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. _ " ' .BUILDIr'll:i b)' 'MH n 'PERMIT NO, 330-75
. 'P.ROPERTy'!,OWNER . . MAILING ADDRESS PHONE 46
:.i;.q\!,9n~61 OAK s 257~ NOR,1'H 35ni SPRI NGrlEl.-O OREGON 7 .2~~
CONTRAGTOR MAILING ADDRESS PHONE 1
KEN CLARI( -p', o. Box, 10881 EUGENE, OREGON 6(j6-8555
PROPERTY LOCATION -INCLUDE POST. OFFICE'
,2040 I'NLAND \1AY @'FILBERT GROVE,
PROPERTY LEGAL DESCRIPTION - METES, BOUNDS
'..: .1:'
TWP
18
RANGE
03
SECTION
11.2.2
TAX LOT NO.
1800
CODE
CENSUS TRACT
17-186
&
GEORGE OAKS /Cdrm
P., O. Box 10881
EXISTING STRUCTURt~_ QN PROPERTY
, " " 20'1() INLAND WAY
lEG~L tCC~S.S. ::N~gEERTY
PROPERTY ;SIZE ~ FT. .
APPl.
NAME
','
MAILING
ADDRESS EUGE NE, OREGON
FOR MOBilE' HOME PERMITS ONLY
, No. of Bedrooms
STRUCTURES TO BE BUILT THIS'PERMI!
, PERM I T' TO CONSTRUCT CAPORIlT
WIDTH
DEPTH
AREA
Connect "to, Existi,ng
TYPE.CONSTRU<;:Tl0N
Sewage System D
SQ, FT. # BDRMS
New System n
VALUATION
'j
I
, ,
. ,"
-"' ,.[.f.SEW AGE DI~Po.SA~ "
,PUBLIC' D:.te:X~SSEPTlC TANK D
':':<'BU'ILDINd . '\ <l" .
, WASTED"SPOSAL ,
.."..-:
PLUMBING'
. PLAN REYIEW
PARK TRAILER'
l%SURCHARGEIIl
TOTAL $ ,
OTHERD
2ij.OO
FEES
Pll.:'MB~NG ,INSTALLED BY
OWNER D OTHER, NAME
WATE~ SYPPLY
PUBLIC ~D.
n OTHER
!
..
.04
24.04
COUNT,Y
'BUILDING & SAN IT ATlON: SPECIFICATIONS
DRAIN FIELD REQUIRED
MIN. SEPTIC ,TANK CAPACITY
WITH DIST. BOX: GAL
'lIN. FT
TRENCH WIDTH,. FT.
OR SQ. FT.
" '
TYPE OF STRUCTURE'
OC,cUPANCY ,~
ZONE
PUBLIC UTll. EASEMENT
~ J
BLDp. .SETBACKS n FT. FROM CTR. OF ROAD RIGHT OF WAY USE ClASSIFICATION
fRONT
40;'
SIDE INT. 51~ 'SIDE EXT.
AUTHORI?ED SIGNATURE- DATE
REAR),'
DATE
, /sl J,. E. Boss BY.,C. HARBAUGH
JOHN SHOOK/SAN I TAR IAN
2/27/7'5
OLM,'
BLDG. PERMIT'- WHITE
OffiCE COPY - WH.ITE
COUNTY TAX - PINK
. . PLUMBING - CANARY
BUILDfNG- GREEN
SANITATION - GOLDENROD
Call.687-4065 to schedule all requ'ired inspections, All construc-
tion shall comply with' Uniform Building Code, D,E,Q. standards,
IMPORTANT: for 'subsurface sewage disposal and co'unty regulations covering"
plumbing. All buildings require a certificate of occupancy bef~re
being occupie"d.
(See De~ails on Reverse 'Side)
"
,
"FORM:::: C55--13
(POST THIS PERMIT ON MAIN BLDG. AT, SITE)
LANE COUNTY, DEPT. OF ENVIRONMENTAL MANAGEMENT
COURTHOUSE. ANNEX, 135' EAST 6th, EUGENE, OREGON 97401.
, '
',,;~.~,
, BQ'ILDING SITE
(~BUILDING
, -TI vJ~Vd
EVALUAT ION 0 ,_ ..~l\
, ,
PER,MIT APPLICATION NO..
::y/~' C,H-T_'~~R O~
SUBD, ,S ION:
:S;<'O'--'~ LOT:
S I \-2.~TAX LOT, \8Oel
BLOCK:
, (), SITE I NSPECTI ON
PLANN ING 0 I V I S'I ON ' Not
, ',Appl icable
-,1..' Zoning 'Ordinance Compl iance: ZoneeA--M\-\( J
2. S'ubd i vi s ion Ord i nance Comp 1 i ance (-.l
3. Requ i red Access ( )
4. Building'Si~e (A~ea; Width, Frontage) ()
5. ,Other (see comments)' , (J
,
COMMENTS,: '
r
APPLICANT
DATE
(Q:B'h /C/t:lr~
f
No Yes, CKID,BY~ uzJ4:hs:-
() (.'i- 6. ~Setbacks from c/1 'of'road,:
( ) (l)J/' Front 45 '
( ) (i1;
( ), ('1
( ) ( )
r
.,J 1....1,;;; "^Lt::f I or
Setbacks from' in~erior lines:
, Side 5'
'Rear .~
'PLANNING DIVISION ACTION P~NDING: YESl } NOl } APPLICATION#
"
BUILDING INSPECTION DI,VISION
Not
App I icab Ie'
( J
( I)
I ( )
( )
, ,
'7. Plans Submitted
8. So; I S t'ab iI i ty (foot i ngs)
9. Flood Plain, '
'IO~ Other (see comments)
COMMENTS:
, ,
'WATER POLUTION CONTROL
"
, Not
Appl icable
YJ
( )
,
II. Meets Department,of
Qual ity Standards.
12. Other (see comments)
Environmental
,
COMMENTS:
, -
r)m
(,) (,),
. (.) ( )
( ) ( )
CK'D
By:&JI~A.'').1r7(
, tDATE
, \
No Yes
'P),n
( ), ( )
CK'D
By:\'~~~')16
" \) DATE"
to APPLI CANT:
, '~~r'Building./ Site In5pectio~: "
, : ( AI, Can be approved. '.."
-1Y C) Canno't be approv,ed at, this time as indicated ,on item NO. above.
. f) Q.;lp, Quest.ions and 'furthe~ information on items ,I through 6 contact the LANE-
oL/ ~~ COUNTY PLANNING DIVISION., Questions and further information on items 7
, , 'V ' through 12 contact the-!-ANE COUNTY BU I LD I NG AND SAN ITAT I ON I 0 I V I S 1'01'1. \
" ( ) Will be held .in,thi~ office,until you can(r,esolve the problems indicated.
( ),Is being returned. " ,
! ( ) Your bu i 1 d inq 'perm it api:> I i c"!.!..i.9!!..Je~_~ bei n,q' ret_urnEpd under senar?t~ cQY'lr
, DEPARTMENT OF ENV I RONMENTALMANAGEMENT
135 Sixth Avenue East Eugene' Oregon 9740.1 ,-
PHONE: 687~4065 '
LANE'COUNTY PLANNII'lG DIVISI0I'lPHONE:-687-4186.
. " \
C55-28
~..'~~:'"
,
','
Date
FEBRUARY 2v, 1975
Permit No,
1'10-7'5
CURB 'CUT:: ,
.:
it.
", ,P'E R MI T
IN THE BOARD OF COUNTY COMMISSIONERS ,Of LANE COUNTY
" WHEREAS, 'the attached application has been fully considered' by the Board c:f County Com- "
missioners of L,ane County, and it is the opinion and judgment of'the Board that the said application
should be granted, and that. a permit should be issued, no'ij, therefore, it is hereby.
. " , '.'
ORDERED"that a
p~> O. Box 10881
or constructing the follo-.ying
permit be'a'i1d is hereby iss'ued to 'GEORGE OAKS
FILBERT'GRO~E
,EUGENE, OREGON
facility:
, 2040, INLAND WAY
for ,placing, building,
. :;
. '
upon the right-of-w~y of <;:ounty Road No. ' "', Mile Post, ,
in strict 'conformity to,the exhibits attached hereto, and,suojeci toalJ terms, conditions, agreements,
stipulations and provisions contained in the application,and'permit, the Rules and Regulations Goy-
erning Facilities t6 be 'Permitted upon County ,Road Rights-of-Way, as se,l forth by the Lane Man-
ual 50.1,90(2) any amendments thereto.. and any other a'pplicable regulations, law or ordinance. '
"
Specia I 'P.rovisions:
1. Dri~eway will be constructed', in accordance with, the' attached driveway approach specifica-
tions' (Drqwing M98-50).
2. Permittee will be responsible for the immed;'ate" removal, of all mud, dirt and debris from the
roadwayand"right of way caused by his operation, le,aving ihe roadwayand.area ina neat,
,?cceptablecondition. '
3. S~DEW~~KS WILL BE CONSTRUCTED' IN ACCORDANCE' WITH THE ~TTACHED SIDEWALK
, SPEC.! E1 CATI,ONS' A;'W DRAW,I NG M98-49. THE STANDARD CURB TYPE ,SHALL BE'
CONSTRUCTED UNLESS,OTHERWISE 5PECIEIED.,
, .
,',
, '
This permit ,is revocable af any time, and will be: strictly adhered to and no work other than
that specifically mentioned aoove' is hereby authorized. , ' "'-,
This permit shall ~be vO,id unless the work herein contempl~ted shall have. been completed, be-
28 ' , '76
for.. FEBRUARY ,J9_., Expires .. 19_.
Date
",
, ,
,P..pproved by Board of County Commissioners
By'
Inspected and Approved'
'iV,'
, '
, -"
;/)'
'_ _' r
", _'4!1J...l.LA.
. Djrector pf -Public
\1orks
By
WHITE - OffiCE _FilE
GREEN - RESIDENT ENGINEER
PINK -_ PERMITTEE
BlUE-'ROAD SUPERVISOR
ORANGe'"":,, BUILDING & SANITATION DEPT.
YELLOW -; REAL ESTATE
C98"79
'_;,~r _- "'-:;.*'__ _ ~," ,~,~
.. .' --". ,~
"'-:_'~'''''''''--~-'''
~ .........--.
i',~..~;j".~
Date
..
f'E3IlUMIY
(-)
~ 19'15
(\
"')
Permit No.
'1};;..15
CURB CUT
.
--
PERMIT
IN THE BOARD OF COUNTY COMMISSIONERS OF LANE COUNTY
WHEREAS, the attached applicatian has been fully considered by the Board af Caunty Com-
missioners of lane County, and it is the opinion and judgment of the Board that the said application
should be granted, and that a permit should be issued, now, therefore, it is hereby.
ORDERED, that a permit be and is hereby issued to CrO'!Q.t; C':Jd>fl
~. O. Oox loeB. ~uGt~C. ~Ut~oN
or constructing the following facility:
rl~!J!:I01T Gllovr; :;tate DIlI.AIIO WAY
for placing, building
. .
'\~pon the nght-of,way of County Road No. , Mile Post
i); strict conformity to the exhibits attached hereto, and subject to all terms, conditions, agreements,
stipulations and provisions contained in the application and permit, the Rules and Regulations Gov-
erning Facilities to be Permitted upon County Road Rights-of-Way, as set forth by the lane Man-
ual 50.190(2) any amendments thereta, and an yother applicable regulations, law or ordinance.
Special Provisions:
1. Driveway will be constructed in accordance with the attached driveway approach specifica-
tions (Drawing M98-50).
2, Permittee will be responsible for the immediate removal of all mud, dirt and debris from the
roadway and right of way caused by his operation, leaving the roadway and area in a neat,
acceptable condition. '
'.
3-
l>IOf.\(Al.ltll WIIl.I. 8~ ItO~YOUeVltD HI "tl:Olilll'Mltlil Qilfll
9PEClfICATIO~ A~D C?AWINO M98-49. lfl~ STANPAnt>
tClUOTlWct-, 'J'I'l.l!G!.l E;iTt-Io;fNteli r;ptCIFU:O.
~~
f
far ATTAtWr.O et~L~A~~
tu~~ TVPG ~h::~'0r.
'"
1JrP
This permit is revocable at any time, and will be strictly adhered to and no work other than
that specifically mentioned above is hereby authorized.
This permit shall be void unless the work herein contemplated
f~~n~A~v r.~~ i6
19_. Expires
shall have been completed be-
forp
,19_.
Inspected and Approved
Approved by Board of County Commissioners
By
Date
By
Director of Public Works
WHITE - OFFICE FILE
GREEN - RESIDENT ENGINEER
PINK - PERMITTEE
BLUE - ROAD SUPERVISOR
ORANGE - BUILDING & SANITATION DEPT.
YELLOW - REAL ESTATE
C98-79
. PROPERTY ,OWNER
GrOtu_ 04K.
SPIUQf'lI"LD
T.
1/"'.
330-75 I
PHONE .,
OIlUUH tc-j;',~)
pHONE
~...(5'Z).
.
I ..,:. \__.;..'
,
"
LANE CO'.. 'TY
BUILDI~". L
BUILDING PERMIT OR MOBILE
MH D
MAILING ADDRESS
?5fi; ~Rflt 35TH
MAILING ADDRESS
,Po O. $1M 10881
..,ME USE PERMIT
PERMIT NO,
'I
, CONTRACTOR /
, K[II Ct./lllK-
CYClIC, ,"-UOH
PROPERTY LOCATION - INCLUDE POST OFFICE
. t ~ '''LAND WilY 'fFFii1!el'lT GllOVI:
l. I PROPERTU.cGAL _D~SrtHPTIC?N - METES, 80U~ _ '
,~:':----UJ'/t/.~~ ~
. TWP RANGE SECTION
t8 03 11.2.2
"
chr ..3.2- dJ-e;G ~
TAX LOT NO CODE
1800
CENSUS TRACT
I'H86
.\
APPL.
NAME
GrOUE OAIt, /Ct.Afllt
EXISTING STRUCTURES ON PROPERTY
20~ hlLANO W...y
&
1>,_0. (MIx 10881
\\ . j \
E'VclltHI!, OIIIC1OIll
HOME PERMITS ONLY
LEGAL ACCESS TO PROPERTY
No"E
MAILING
ADDRESS
fOR MOBILE
.\
, -""I:,;'; \
\-~ ,PROPERTYj'SJZE'~ FT.
WJDTH DE~TH
,
\
AREA
No. of Bedrooms
STRUCTURES TO BE BUILT THIS PERMIT
\
Connect to Existing
TYPE CONSTRUCTION
Sewage System 0
SQ. FT. #BDRMS
New System 0'
VALUATION
PC"MIT TO eoM$TllU!;T CA~ORltT,
'.1
,/
,
I
J
II
, I'
I,
.~ MIN. SE'PTiC"TANK CA~ACITY
! WITH DfST.- BOX: GAL.
t
.0'
, ,lM.t:l1+
COUNTY BUILDING & ,SANITATION SPECIFICATIONS
DRAIN FIELD REQUIRED
,.,..
"
1',
'J.
~. :!
, J,
1v
:~';
i 1, ",
it
it'
,'~ ,.'
I"
,h
. ,""SEWAGE DISPOSAL
; 'PUBLIC D txt,.SEPTIC TANK D'
.'-;-"'BUILDING It
, WASTE DISPOSAL
l'f ... '.. .', -
, PLUMBING
, '
PLAN REVIEW'
, '
PARK TRAILER
.1~\t^lUlI.. .
TOTAL $~
OTHERD
i!4.00
FEES
PLUMBING INSTALLED BY
OWNER D' OTHER: NAME
WATER SUPPLY.
PUBLIC 0
D OTHER
__" '1"
-I'-,
>r; ,r.
L1N. FT
TRENCH WIDTH FT.
OR ,~SQ, FT.
I
5\, '>...'
i
" ~ i
\
"OMIf SIINIl/SII" 11M ,..."
DATE
,
..-. ./.
;'1::
" L;
~. .,~'.', "
"
'1' .
:'l-<:-!
I'
,I
I' :,
"1..
lj\,1t.
f-,;-j .
,
,
I
i
'--
; TYPE OF STRUCTURE
5H
OCCUPANCX
J
ZONE
PUBLIC UTIL. EASEMENT
i BLDG. SETBACKS' _ FT. FROM CTR. OF ROAD RIGHT OF WAY
t FRONT 451
/s/ J. t. lJtIlNl ." C. 'HA"II-Al,lGH
USE. CLASSIFICATION
SIDE INT. 5t SIDE EXT.
AUTHORIZED' SIGNATURE - DATE
REA,!)'
2/!7175
BLDG. PERMIT - WHITE
OFFICE COpy - WHITE
COUNTY TAX - PINK
'PLUMBING -.CANARY
BUILDING - GREEN
1 SANITATION _ GOLDENROD
~",-"." ,.', ',.
...... ,_,.J,~, _ ,_
'" ' -
! .
Call 687-4065 to schedule all required inspections~ All construc-i
tion }hall comply wilh Uniform B~i1ding Code, D.E.Q. standards
IMPORTANT: for ~ul?su'r.tci~,~ js,~~age dis'posaland cou'nty regulations covering
plumbing. All buiJdings require a certificate of occupancy before
, '. ", \ ,.,~.b~ing occupiee. \, f... "- ~ ..
<' '. J~ "cd' ' (See' Details 'on Reverse Side)":' '
~ \ ~ -.f' - ,\ ..'
,
FO'RM ::::: C55-13
(POST THIS PERMIT ON MAIN BLDG, AT SITE)
LANE COUNTY, DEPT, OF ENVIRONMENTAL MANAGEMENT
COURTHOUSE ANNEX, _135 EAST 6th, EUGENE, ~REGON 97-401
. ';.<,~'"
;.'.,...>>....-, "-~<<
......
~~~
"
'.
SITE I NSPECTI ON
ApPROVED Cl
DISAPPROVED Cl DATE
INSPECTOR
REMARKS
FOUNDATION INSPECTION
ApPROVED;----Y DISAPPROVED / / DATE INSPECTOR
REMARKS r) 4:'16 ,,1/AUli!/ J/f(I'{/{":~'f~ a.-ie Y 7-
/' j'
/ I'
"
FRAMING INSPECTION
/
~ r--7 ~/l.i?e
ApPROVED' ~/ '~'SAPPRDVtD 1--1 DATE j ~ r-/
~,
INS PE C TQR..---7--..
REMARKS
LATH OR SHEETROCK INSPECTION
ApPROVED /, 1 DISAPPROVED ;----y DATE
INSPECTOR
REMARKS
FINAL INSPECTIOY
ApPROVED ~ DISAPPROVED
/'}
.., ,.,' /{/
DATE j '.21/-7~sPECTOR //
, I ' (,co -,
/ 1
REMARKS
CERTIFICATE OF OCCUPANCY
READY TO ISSUE I I NOT READY TO ISSUE /7 DATE
INSPECTOR
REMARK 5
'33()- ?S'
~O/fO ~
'~-_\..':"P'
/I')
r:; ./,
- (
r:' 0
'. ,-.{
. .~' ,
,
-.;-'
NOTE:
NO PI?RMlT
?~6,-.:zJ4-Y
..Phone
LPp-,"7~~rr')
---Ph,?ne " ,
O:S", Rt/G.;, , ,u.;~
::~iViSi:~~/t~f =;~3;x LotB:~ (;
,ACCESS 'TO PROPERTY (Road ~~m~) '1';j)/;;;;, -I1l1l1.;QO~ b
Exis~ing Stru~tures .on Property:. "A/~ p~" ~. ~ : .
Proper~y Location" _- Address/Direct;ons':f - -:r. In bnrL,
"
;:"
. Code
Census
Tract vr-/~
Width..zeDepth 91 .
~.ro'per'ty, .Acreage
,.,.
I
/
"
'~l/
",/
Below for Office Use
~~s,
- ({
Mf"ll?; Ie...-
Oil I v XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
c, Sq'. -Fe, ,_ "", IIB# Valuation-
.. ,/
'R"
/
. '
/
,.f'
""
~~,
" ,
~
SEWAGE DISPOSAL::
Site Inspecti~n' #
FEES:
J
PLUMBING: ,
Insi~lled 'by Owner
or )~ew System ~equired ~
Na!"e of :ommunity or Public' System Sp'" 'lJ~'e~
, WATER SUPPLY:
Well
,Spring
E;>cisting- .Sewage Di~posal' Sys~em"
',. . . Public .~
. Qther' . COmIDuni'ty .. . "
i
Bldg. ,
Waste Di's~p.
Plumbing
Plan Review'
Mob~le Home
1% Surcharge
Other' -~ N~me
"
,- ~
.q-), -
4. ~
PLUMBING FEES:
~,'
II of, Fixtures
Sewage'
.. Co,p.nection
Water
Connection
~
TOTAL
,So, -
,o!! b,'CASH '.-
qLJ"~t/' ~'v~
I '+ ' ';:: I.
~r.
.'
',PLANS ,FURNisHED
- ,t< ~
FACILITY J:>ERMIT
"
>~
I,;".'IYE~ ' ~ 0 ~ ~ m c::;J NO
~.:~gnature of App1~cant. . .~ . ~ ;t'~A j
".Fee Received By:"., Date:
,
, .
Min. Septic Tank Capacity q rfJO .
'J..':hL.'rrf/cfdtD Jp' a..
j>tI,IAi:7 .f,h!'_C-. '
D:qlirifleld _,Required -. ~ine?~ Fe~'t----& b
I'h.l:4t\"u J>-.. oF ',-(:-On '.JCe-e',~
, '"~xlmum"Depth
,~ p~~..f',
.-
c
Typ~ of Construction
f1'fJ " 9roup
)
. fire Zone'
'Us~ Classification
" ~ "". .
"
Bldg'Setbacks
Front_ 4,c;'
from Center of Road 'Right .of Way:
Side Int. .~,. ,.. >"~_.-_.o. =:;"'~""~'
, ~,
Rear~
~ "".....
"r
Zone /?/f-MI-j'
~
~o/;,h<
I ~
DATE:
ATE)1~-JM~d
IT DE;r:ARTMENT ,OF ENVIRONMEl'lTAL ~~~ENT ( , '
DATE:
:2,-", j II - J'.J
C55-12
LANE
,NOTE: ,NO PERMI,
,ILL BE ,ISSUED UNTIL THis ApPLIL
LON HAS
, -...:::"-,..
" c '-::::;? r;,,' "-\'"
., PERMIT ~C~S-
BEEN APPROVED
"
. Co'NSTRUCT;?N ~ MOBnE HOME CJ PLAN REVIEW c:::::J CHANCE OF OCCUPANCY [==:J
CJ OWNER~-nE>~~~P V~) dS\'\8, '\"0~~ ~:~. . ~~\a-~~~
,9<2 CONTRACT~R~~e:- ,G"aL(St)~ X ~M\~':~~n;::~R~A~
'O.S. R~)n '" lo \o~ '
';"'p.\PZ~ng~- D~ Section ( \ .~..::lTax 'Lot \. ~ Co~e
S'ubdiViS~ . \. .\o'..e ..... {. ~~t.' ~ BlOCk' Lr,.. P;roperty Acr~ag~.
ACCESS T; PROPERTY (Road Name) ~(~')~~ ~\Q~c:\,. ~ ~, . \
EXist,lng :?t-ruc6.~.res ~n Propert~ ~ ~: -
"T ~ \. n. '"' A.~ ~ X--~
~u~\o d (lh!;:i'~,:~ \
APPLICATION FOR:
Census
Tract \ ('\ ~ ~AL-,
Width~Depth
, ,
Property Locatio~.~ Address/Directions: ~c:)~ C)
~'"") ~,.\ \D<.Qv~ ~v~
\.
",
,
....-,
Below fo r Of f ice., Use Onl vXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
'--- ~;,~A~,'" . f Sq.'-3..C..,/ X::)~~ed~.t~,~(Jl~a~~.:St)\ c.,~
C"".....,""'~,-~,.- ~.l~-'YC>, ~' ,. ' 't\:/ '
, , , /'
/
---
SEWAGE DISPOSAL: ,~ "-I.
Site Inspection c.--'I" t x:..~-'\
Existing Sewage Disposal System
CJ
or New'
WATER SUPPLY:
Well
Other
,~g~:e~
PLlJ~G:
Instal~ by Owrier
Coimnunity
G:=:J
c.::J .
Name of
C=:J
FEES:
'Spri~g ~
'd>-.lC<C
Public
:?ystem
c.::J
/
_ It of Fixtures
Other c.::J Name
Sewage ./' ,
, YE.S CJ NO [=:j YES 0 N~ d
,70ignatur : of A;tHcant; ,(~ ~.W..~..........
i Fee R7 i,;,ed BY:~~~ .~ate";J ~~ \<\~
J '
;" J
Re~U,ir~d vi Feet
"
Water
Connection
Bldg.
Waste. Disp.
Plumbing
Plan Review
Mobile Home.'
1% Surchargf?:
'PLUMBING ,FEES:
c,:-t,
FACILITY PERMIT
';'
TOTAL
I
.:::i.N'~
'cii~d;~;{.d- '
.:r :
C]
Min. Septic Tank Capacitv
Drainfield
." Maximum -Depth"
.Type o{'Construction
.1)'#
'Group'~ -,-
Fire Zone
Use .Classi~ic~tion
Bldg'-Setbacks -,
, A~I
Front ~
from ~enter ~f Road Right
,,c-I'
"~ Side Int., _-)
of Way:
; ,C''<.'._ ~
I
Rear~"
Zone
QA.-M~
~~24~~
~ (55,';' '.'
DATE:
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DE ENT OF ENVIRONMENTAL MANAGEMENT ' ,
LANE COUNTY