HomeMy WebLinkAboutMiscellaneous Septic Tank 2010-1-25
, ..
SEPTIC TANK DECOMMISSION
(ABANDONMENT)
Township t 7
Range-,,'~ z.~
Section/1/4 Section 4:3 /
Tax Lot OJ,()t)1)
If you are connecting to an area-wide sewage collection system or you are replacing your septic tank,
please don't forget to properly decommission your septic system. An unattended and forgotten septic
tank can become a serious danger for everyone's safety, Present Oregon regulations require you to
properly decommission the septic tank as described below, Please have this form signed by the
appropriate people and return the completed form to:
LANE COUNTY SUBSURFACE SANITATION PROGRAM
Public Service Building 125 East 81}l Ave Eugene, Oregon 97401
Pumped of sludge on
Name of Property Owner vY\ I~ r..MJO J..- :\' _ 9Rn ,I'>e JU
Septic tank located at .;JSt"t". GIlA-'AJI'tI '/J'-''f'A- !iJ12... .sRA I?I<
, ,
/-25'- 7.011> by '"""\7A,.k ~_ .
(Date) (Signature of Licensed Operator)
License ~ -38314 at!h-;-/S'ID6f3
The septic tank located at 2.. SIDe.. t:.6l......JIl:>lWI.q-A -:i)f!... SPR. nR..
, ,
t!PfIJl!f-f.+.....C,CJ>F) ,
backfilled with 'BREI OP e.. '_.:. :'~I'I gpo"lll after being pumped of sludge on
was
rS?-/4/ -
,/ . ,
Signature 0
.f'
1 - ?'- 2.01 D
(Date)
erator (may be owner)
Oregon Administrative Rules (OAR) 340-71-185 Decommissioning of Systems,
1. The owner shall decommission a system when:
a. A sewerage system becomes available and the building sewer has been connected
thereto,or
b. The source of sewage has been permanently eliminated,
2. Procedures for Decommissioning:
a. The tank(s), cesspool or seepage pit shall be pumped by Q licensed sewage diSposal service
to removal septage
b. The tank(s), cesspool or seepage pit shall be filled with reject sand, bar run gravel, or
other material approved by the Agent, or the container shall be removed and properly
disposed,
H:\LMD\SANITAlTON\FORMS\Septic Tank Decommission torm,doc
Lane County SUbSurface Sanitation Program- 1Z5 East 8'" Aw, Eugene OR 97401 (541)68Z-3754 Fax (541) 68Z-3947
Concrete: Irlurious to eyes.Causes ski1 iTitaboo.Conlains PortIa1d Cement Read the foIbNirvJ WlrTing before ~: Ccrrtad wi1tl wet,
~ araet'e, rratcr, c:errent ()'" canern rrixlLres cal caJSe ski! iTilalioo, SEM!re ctm1caI buns a- serio.Js f!fe dErna;Je. A..m cc:nt.EK:t 'oWh
f!j$a1<fsm, Weaw<tffprocigk>tes, afUly-bJ/lmld, b1g-siel>Ie sti1. hJ.Ienglh """'" "..;Iighl_ eyeproledionv.llen1oYOl1<i\i v.i1h It'e;e
_, W\<lU havetlsfa1d nwet"'""""', usew;jerproclbOOs tool are i;lht at /l'eq,,,..; tig/l"""lh tl keep ",""",,,1001 I'o.Wg i1lD/I'em.
WliistW'goroete,v.eakreepolstlp1lledkroes.A""'coo1aclv.i1h"'lalt'e;ernateials,washclf ,.t,.', v.i1hfreSl,deirlwa!llr,hiectcoo1acl
IIm.9hc:Jam,j.as~soprtlTlllymselt'e;e_Ioo1c:Jam,j,Seek_rna<IcO_l\<lUhaveper.;islentasevere
discl:rrlort.ln case a eyecootac( 1\Jshv.i1h pIo1lyawa!llrfa at....t5 rrilJIes, C<mA_ i1]redalEIy, KEEP OJlaread1 a_I User
a]rees to rrxM!'/ !tis wari"g to cf pa-scns wOO may use Cl ccme ilto a:ntact \Wh wet (i -r" :" ,.'[ cmaete, nntr, C9Tla1t ex cenent rrixtLJes.
Aaareaates: Proi:lrged nhalam of 00sl. floo1 a p.teI piOOld may re haza'titxJs,iJ ytM heatl. Meastres t:l cootroI fLgitive dust shook! be talen
.... tmlO>;j !lis pnxltrt Hol Asr!'a~ .,,;;; rUsa-<e fure;, A"Iid lreOIIlg lure; !WJ, I\sp'lOI ""Y ca.oe severe """ Wea ~
salel/gea (fooJ """'" pa11sinl Qlates), WbtrnOO, cxdv.i1h...,."..; see a p/rf.lija1,
Water added at customer's own risk. Additional water added to concrete will Property Damage Indemnification & Release
reduce itsstrength.Buyer's agent agrees to occept responsibility forreduced strength The cperata' d ttis ~ r:A heav,' eqUprneri, WI ~ 1his RE-
duelowaleraddedabovedesign. lEASE to)'OUb"yo.rsgMLre,isdlhe~f1atthe~ctttis
macI1i'eyn/l'e"""",reqLi'edtlpeOOmos_v.i1h\<lU""Y
posslly ca.oe danage tl /I'e I'mises a 1'OPE'1Y, ~ is os Wish tl "'I>
\<lUn_lhalwel3\,btAn_tldoffis,/I'e~isaski1l
Ihal \<lU sign lis RELEASEe" rooideatia, a /I'e ~''''_'''' a /I'e
seier aifsarltradv.i1h 1re,I /I'e II'dernigrod, i'e'eby INDEI.tlIFY /I'e
seier "..; ifs elf!lk1;ees fa "'I danage "..; fa aI cfOms tl /I'e I'mises,
txJldilg,ufifypipefinesac3lfes,fEIeJtoonefi1es,dli\'ewaya_
appurtenar<:es,at:
Anived at job with
inch slump.
o
Added _ gal water ,at customer reque~t
Other additions
TeslcyliOOers
taken
.
Received
by 'X
Buyer's Agent receipt of' product and approval of any added items.
The addition of any extra products to our mixer may void any warranty
expressed or implied by the seller. The seller accepts no liability for any
personal injury Incurred by you while adding additional products to our
mixer.
Signature of Owner or its Agent
t= ~t.: J~bSl$'Start D~sCharg1
Drivers'
Comments
and RELEASE the seller and ils employees from
any liability. .
CUSTOMER/OFFICE
~1
2569917
Unloading & Standby Excess unloading will be
charged at posted truck time rates. Truck standby
time charged at posted truck lime rates.
limited Warranty The only liability of the seUer fOI
product defect is (he return of the purchase price. In no
event shaJrthe seUer be liable for any direct, indirect,
incidental or consequential damages resulting from
the use of the products or arising out of breach of any
warranty. All claims for damages or shortages must be
made Within 24 hours of delivery.We do not assume
responsibility for any damage beyond the OJrb line.
Signature of Owner or Its Agent
JGtNE 8141' r:
,00~ IJEt I,
FUGE M. fJI
)"-1 18.:,. ~ t~10
(j i. VEL
r. II,HWA
o
-rGDELTKT090408
Finish ~'SCharg'reave :JOb Site Arriv: Plant I
Order No.
,1~l0] ,
Companyl
Cust. No. Customer Job
"'>48,
Customer
U!>I" ,01'. WATE:,R ,Ef Ii ICE'S
Customer POI
Phase Code
TICKET NO,
b\ll~ o.
Delivery Address
;';:~b", t;RANL 'I 1ST ~ D~
Delivery Instructions
:i~'F I ,Gf Id '. T 1
Load Qty Delivered Qty
';0 4 5~
Product Code
Order Qty
;0
)( J
DUE UN JOE; l'ME
'1;:, -~0
PREU TRUCk
L.OHD COII~IT
LO~~ Sizel!'"
UOM
Product Description
,\!II!! t I [ut-
1111111!1I11) 111,1111]11I1J1111I1I~1I1 JIIIIII
Driver
JrRP~
Co. Proj. No.
BRUWf'S 1211/'
III 25 III ~
Dole
Map Zo-e
E" E
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Unit Price
Amount
/
~
r~ I N I MUM l UhD CHI,," .c
-t\jl fHG
..
Tare Weight Trailer Trailer Tak~l'!J~
PitlPlant Sales Tax
TOTAL DUE
ICh'C:__~_1
Prtld.No,..)
OescriptionJIlIl,!1 -'t' 1 }-.ur Slump 1{.I~Type
Haul Cd.
Tnk: ~ Gross Weight
CC
Us.
Jan 27 10 12:39p Oregon Water
Jan 26 10 05:4Sp Mike Kuenne
5413421746-
541-
p,1
p. !
ArE Equip...L.";'
~Pecialty
Services
Inc..
Invoice
i
349WI~
Springfield. . ~47'l
(541}485-8930 Fu: 541)391-0202
CCBf# 154093 ~Q# 38114
Date Invoice ##
112612010 11294
Bill To
OregonWater Services, Inc
30086 rr.ul>AAL LANE
EugeDe,'Oil 97402
i ~Ob l.ocf'icln
~ "2-S(P~ (9U1J~
c;;.fUl.,,19~
II I s.-t4- JJ L
0/1'-/77
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,;~ .~ "
... .~ '
T8III1$
Net 30
Rep
MDK
~iP
Ui6f2010
EO.B.
project
-I '\i~ ,..'::.,~,
P.O. 'Nuinber
'.. .....-.,...."
Quantity Item Code
1,000 PUMPING
~;"';or ,
PUMPED SEPTIC T ANK/F6R TAl' K
ABANDONMENT
Price Each
0,28
Amount
280.00
f:;.m T~,
OC(::;(.',u:Vi.a:t.e-r ~ ~;~,.." _, .
JO(}ll:; F.EDERI~ L L:';~'
EU15'~ne: OR 97~ CC:
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TIilii11t~yoU for'yOUr business.
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Total
$280.00
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