HomeMy WebLinkAboutPermit Building 1975-3-10
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'\-"LA~/.~~Y
BUILDING dC:
BUILDING PERMIT OR MOBI&OME
MH D
MAILING ADDRESS
16~0 SOCTN A STr.~"T
MAILING ADDRESS
USE PERMIT
PERMIT' NO.
:m-7.)'
"
~
PROPll'..TY OWNER
;:E,';]:,~7 3:107liERS
CONTRACTOR
Spi:ltlor IEl:>
PHONE
Cr.~CO' (~:'>-4\f2;
PHONE
~--Ai:t:
PROPERTY LOCATION - INClUDE POST OFFICE
;~2~ DElRos~ AV~~UE
PROPERTY LEGAL DESCRIPTION - METES, BOUNDS
V~11A DEllE
LOT 3 SlOCtl 1
TWP
RANGE
SECTION
TAX LOT NO,
CODE
CENSUS TRACT
17
3
24.3.3
16<)0 SOUlII A STREET
EXISTING STRUCTURES ON PROPERTY
t:O~IE
LEGAL r=CESS TO PROPERTY )
\ iJ~lrlOSE AVEtJUE
PROPERT~ - FT. /
WIDTH DEPTH AREA
APPL.
NAME
&
KePHART B:10THERD
MAILING
ADDRESS SP:11 r:Gr I ElD OREGON
FOR MOBILE HOME PERMITS ONLY
No. of Bedrooms
STRUCTURES TO BE BUILT THIS PERMIT
i-1A III
Connect to Existing
TYPE CONSTRUCTION
1134021.80
'516 0 5.30
Sewage System D
SQ. FT. :;t BDRMS
1J\1E II HIe,
3
New System D
VALUATION
24,7" 1. 20
"
~ 2,T34.~_.
V27\11!1)",-G:"1- ,
CiAI'A<'E
...
.r
v
"1 -':"-'24
oJ ~ ,_
SEWAGE DISPOSAL
PUBLIC 0
BUILDING
WASTE DISPOSAL
PLUMBING
PLAN REVIEW
PARK TRAILER
l~-~Dur:cHAnaF.
TOTAL
"
SEPTIC TANK
D OTHERD
$_121.00
0;0_00
~1.00
FEES
PLUMBING INSTALLED BY
OWNER 0 OTHER: NAME
WATER SUPPLY
PUBLIC 0
D OTH ER
1.<;:;>
$ :>m <;0
COUNTY
BUILDING & SANITATION SPECIFICATIONS
DRAIN FIELD REQUIRED
150
UN. FT
DEPTH 30"
TRENCH WIDTH FT. OR SQ. FT.
MIN. SEPTIC TANK CAPACITY
WITH 0151. BOX: GAl.
900
TYPE OF STRUCTURE
5tJ
BLDG. SETBACKS u FT.
FRONT ~J I
OCCUPANCY
I (1,. J
ZONE
PUBLIC UTIl. EASEMENT
FROM eTR. OF ROAD RIGHT OF WAY
SIDE INT. 10' SIDE EXT.
AUTHORIZED SIGNATURE - DATE
USE ClASSIFICATION
REAR
cO'
hI J. E. OO~!1 Dr C. :iAflOAUClf!
JO:'HJ SHoc:(/~Atll TAR I AN
DATE
3/1oIT5
DLil
BLDG. PERMIT - WHITE
OFFICE COPY - WHITE
COUNTY TAX - PINK
PLUMBING - CANARY
BUILDING - GREEN
SANITATION - GOLDENROD
Call 687-4065 to schedule 011 required inspections, All canstruc-
tian sholl comply with Unifarm Building Code, D,E,Q, standards
IMPORTANT: for subsurface sewage disposal and county regulations covering
plumbing, All buildings require a certificate of accupancy before
being occupied.
(See Details 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
~ILDI~G SITE EVALUATION. <JS e... H.
(~arIL~'ING PERMIT APPLICATION NO. ~/-7"""
() SITE INSPECTION
PLANNING DIVISION Not
Aool icable
1. Zoning Ordinance Compliance: Zone~~ ( )
2. Subdivision Ordinance Compliance ( )
3. Required Access ( )
4. Building Site (Area, Width, Frontage) ()
5. Other (see comments) ( )
COMMENTS:
T *? R 03 S~~'?~AX LOT
SiiWr'VISION: :
LOT: BLOCK:
~
APPLICANT
DATE
No Yes
() n 6.
( ) (h
~ ~ ~B
( ) (~
PLANNING DIVISION ACTION PENDING: YESl ) NOl } APPLICATION#
BUILDING INSPECTION DIVISION
Not
Aool icab 1 e
~~
((
7. Plans Submitted
8. Soil Stability (footings)
9, Flood Plain
10. Other (see comments)
COMMENTS:
WATER POLUTION CONTROL
Not
Aoolicable
( )
( )
11. Meets Department of Environmental
Quality Standards.
12. Other (see comments)
COMMENTS:
No NS
()
( ) (
( ) ( )
( ) ( )
No ~
() ( )
( ) (,)
~o
CK'D flY .(~~~hs-'
Setbacks from c/r ~f)road:
Front 50 '
-s.i-de-Ext~r i Qr ~
Setbacks from Interior lJnes:
Side I~
Rea r :2\:) ,
CK'D By:C2~L~.7'-'7J
...~
CK'D BY:jU.
3/~Q'
DATE
TO APPLI CANT:
{fur Building / Site Inspection:
Can be approved.
( Cannot be approved at this time as indicated on item NO. above.
Questions and further information on items 1 through 6 contact the LANE-
COUNTY PLANNING DIVISION. Questions and further Information on items 7
through 12 contact the LANE COUNTY BUILDING AND SANITATION DIVISION.
( ) Will be held in this office until you can resolve the problems indicated.
( ) Is being returned.
( ) Your building permit a,Ppl ication fee is being .~~t.\l.'=.n.~d un<!er seoarate cover.
DEPARTMENT OF ENVIRONMENTAL MA~~~MtNI
135 Sixth Avenue East Eugene Oregon 97401
PHONE: 687-4065
LANE COUNTY PLANNING DIVISION PHONE: 687-4186
\'0" 1~
3-" ti..
C55-28
,
LANE aNTY BUILDING PERMIT OR MOBlaOME' USE PERMIT
BUILDING d~.u0.~ .0..__ PERMIT NO.
~ ~
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; .~
.' .
.,
PROPERTY OWNER
'.
MAILING ADDRt:SS
,.. ,
k ,':JV:: ^
MAILING ADDRESS
PHONE
"IT
:.>~-'. ~ C .,,"
CONTRACTOR
PHONE
PROPERTY lOCATION -INCLUDE POST OFFICE
." I . J:
PROPERTY LEGAL DESCRIPTION - METES. BOUNDS
',j~'
. ~ ......
TWP
RANGE
3
SECTION
(~ ,C '0.:1
TAX LOT NO.
CODE
CENSUS TRACT
APPL.
NAME
&
EXISTING STRUCTURES ON PROPERTY
'01
LEGAL ACCESS TO PROPERTY
,"..-,-
.,
MAILING
ADDRESS :..J
FOR MOBILE HOME PERMITS ONLY
No. of Bedrooms ~
STRUCTURES TO BE BUILT THIS PERMIT
. )....PR9PERTY SIZE - FT.
WIDTH DEPTH
AREA
"'"\..s:.-:---- ~ :::..-.'. ...,--~~...1 "~-' '....'.: '- .,,' ... "b
~ . ,,-;.~ -- CQrinec:f-fo~ Existin9\':~e.wct_~,~SY.5tem. j
TYPE CONSTRUCTION SQ. FT. ;: BDRMS
, '
New System 0
VALUATION
"
1,.. ~.
.0
,.
\
\ ,
'-".J
\''1.
~\.. \ ,,\,>
: ~ ~ \
C.._'
,
.,
,
'.
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->
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SEWAGE DISPOSAL
PUBLIC 0
BUILDING
PLUMBING INSTALLED BY
SEPTIC TANK 0
,
OTHERD
,
'-
FEES
OWNER 0 OTHER, NAME
WATER SUPPLY
PUBLIC 0 0 OTHER
WASTE DISPOSAL
PLUMBING
PLAN REVIEW
PARK TRAILER
\ .' ),
,
.
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"
,. .:-
:"l '::-.:._::~
...,..,--
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---..., ..
.. , ;:", _,",.::1'; -..,,,'_:.-,'
'----,:;.:--
.,
TOTAL
$
MIN. SEPTIC TANK CAPACITY
. WITH DIST. BOX: GAL.
COUNTY BUILDING & SANITATION SPECIFICATIONS
DRAIN FIELD REQl,IlRED
L1N. FT
TRENCH WIDTH FT.
OR SQ. FT.
.\ '.
~\''''';' :-:..~\
'"
"
~ ~. \ t ;,':
\
TYPE OF STRUCTURE
OCCUPANCY
ZONE
PUBLIC UTIL. EASEMENT
.'
BLDG. SETBACKS. FT, FROM CTR, OF RpAD RIGHT OF WAY
USE CLASSIFICATION
FRONT
SIDE INT. SIDE EXT.
AUTHORIZED SIGNATURE - DATE
REAR
.
.--
L
/1'
~.: 't.
"
DATE
BLDG. PERMIT - WH ITE
OFFICE COPY - WHITE
COUNTY TAX - PINK
PLUMBING - CANARY
BUILDING - GREEN
SANITATION - GOLDENROD
Call 687-4065 to schedule all required inspections, All construc-
tion shall comply with Uniform Bu.i1ding Code, O,E,Q, standards
IMPORTANT: for subsurface sewage disposal and county regulations covering
plumbing. All buildings require a certificate of occupancy before
being occupied,
(See Details an Reverse Side)
F'"ORM::: C55-13
(POST THIS PERMIT ON MAIN BLDG. AT SITE)
LANE COUNTY, DEPT. OF ENVIRONMENTAL MANAGEMENT
COURTHOUSE ANNEX, 1:15 EAST 6th, EUGENE, OREGON 97401
r ~
.
.
. '
.
S! TE INSPECTION
ApPROVED ~ DISAPPROVED ~ DATE
INSPECTOR
RO':'!\,RK S
--
FOUNDATION INSPECTION
ApPROVED ~ D, S"PPROVEDj J' DA:E tl-,,~ ~~;NSPECTOR
REMARKS [,; It ti ..t'~O.___ .fj-t....,jI.;L;~ ~ ~ d . N;'6t:.
/ ,-1
~. , /,~ '# ,- . -"Z},
tJ-If. ~:'~o..4;- - -W=->~'';l'J -bl,-
, - . \I'
&~,
l_"A .:.
{?i (,,r--
/\ ~
{'-/
FRAMING INSPECTION /
ApPROVED J1Z!- ;':APPROV~D DATEtj-/~"7fi
REMARKS ~~o{ J2 tI-7i'" 1f() t::i---
. i} } ,
- .
(~' /Z-'
INSPECTOR ,(%: __" /.
LATH OR SHEETROCK INSPECTION ~~
ApPROVED / L/I D'SAPPROVED /I DATE1(-:4:]vJt' INSPECTi'-7. ,. t!2.J
~.~_ ~, >'7:-iLL/ 4,J/
REMAR~~ .:_ :"'~~,' '-1l_-~..A":e1;. l' '''''1'='7-~ #_.r..~_. ~
, /, .-' I
FINAL INSPECTION /
-./ d,,!' "'/
APPRDVE.D L!!J DISAPPROVED ~ ~ATE '~'''''''fiI'fJftJ
REMARKSA~J ~~ .r.tJ '~rt(
- - I
();( /' I
I NSPECTORf!::L~- (_........ "
CERTIFICATE OF OCCUPANCY
READY TO ISSUE / / NOT READY TO ISSUE ~ DATE
INSPECTOR
REMARKS A
/J //
----~e~:%7 _
J 71-7.J-/~~ 1~,2f\LJ~
7
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i'f1
Si9nature p, . J.A p--.e.'~
CERTIFICATE OF SATISFACTORY COMPLETIO A '
For Sanitarian Use Only: Date: 't-~1---75
In accordance with 1973 Oregon Laws Chapter 835. Section 214 this certificate is issued
as evidence of satisfactory completion of a subsurface sewage disposal system at the above
I oca~..1 o!)..
~ Approved: System Installation conforms to current standards
c==J Disapproved: Does not conform to current standards
Remarks:
INSTALLER:
Comp rete top
INSTALLER'S NAME
JJIJ.t
No. living
II ~A.b~
Units Bedrooms
Septic Tank:
Ft. from well
Steel 0
Ft.
Diameter
Inside
Length
OWNER
NAME
Dimensions:
Width
k'rouAOT
~onTUC'OC:
HAILING ,,,~,, "^"~" A
ADDRESS
Length of L j~~;:~[':~ -I T~;ric'\i'l
''lo2f1.m. 4. 5. 6. Width).
;'Iot Plan (see instructionsl:
. ,
) .~~
.... ) .< ."
J' . . , /',
.1,) ""') -.:
,'':\' ,. ~"; " .:~
(- ~ .(~. , , .,1
\~, ':'.. ",J
'~/~ . .,.y
'-0;,....._ .., ,. :/
,._~~t ;-~~/
Date
C55-11
.
PROPDSE~WAGE DISPOSAL SYSTEM RECORD ~ '. .
part of for~ signature and submit both copies with appl icatibn. ... .
PERMIT NO. ,71-7~
PROPERTY ADDRESS
JS
Baths
DELRoSE
Basement
Yes No
Water Supply
Public Other-List
Concrete ~o. Compartments I Gal, Capacl ty I (It) f)
Tile Disposal Field:
Depth Distribution Box: Yes V No
Other Distribution-Type
Total Sq.
Ft."lbD
Feet from
WEll
Lot li ne
Front
1Ft. Between
Lines 11..
Rear
IFi Iler Below
lnJTile I. in.
Foundation
Side
IFi lleI;.IFi ller Depth
Tvpe I 2 Above Ti Ie J.
I
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t)L~ L fRo' t-
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r-r
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---- - ,
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161r
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rp
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ol 71
-II,.rl
f't fr
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salt~~~ s Signature
LANE"^OOUNTY
STATE OF OREGON DEPARTMENT OF ENVIRONMENTAL QUALITY
Call 687.4065 to schedule all required inspections. All construe.
tion shall comply with Uniform Building Code, D,E,Q, standards
for subsurface sewage disposal and county regulations covering
plumbing. All buildings require a certificate of occupancy before
being occupied,
(See Details on Reverse Side)
r-~-'"
I
, 'LANE Cay
...1
BUILDING D.'.
PERMIT OR MOBIL.ME
PROPERTY OWNER
BUILDING
MH 0
MAILING ADDRESS
USE PERMIT
PERMIT NO.
, '
"
I ::i:J,l': ~'
L,;;; ~::).~.:: fi ~70C~:Y
S:?~lf:Jt;C~i) c';:,'C:~'
H~._.n' "
...: .h..J
CONTRACTOR
, r ^" ,
I" ,0...
kr. PRO~E~:Y ,l~:~T~ON ~~~l.~~DE POST OffiCE
1/..".". .,,[.1;..._.,
- PRO~ERTY LEGAL DESCRIPTION - METES, BOUNDS
"1' '.... '--',' fe> "O'f ';'l r~. c~~ 1
_. ,~IT'" ~d,' l;;;. ;; .... "tA.~
TWP RANGE SECTION
I! ,'.1 ,." '.) .,
~ J ~-J.J.;)
MAIliNG ADDRESS
TAX LOT NO.
CODE
CENSUS TRACT
APPl.
NAME
&
MAILING
ADDRESS ;,:":1! .:~~ t Po!,,) Jr::re::::1
FOR MOBILE HOME PERMITS ONLY
No. of Bedrooms
EXISTING STRUCTURES ON PROPERTY
::C:;:!A:'Y =-~c'n~e:;G
;~~~:!:
~C:;a QC:.mc !'1 81';SS1
LEGAL ACCESS TO PROPERTY
(J!!I.r.(;,"~ t.V[;(,:::;
PROPERTY SIZE - FT.
WIDTH
DEPTH
AREA
Connect to Existing
TYPE CONSTRUCTION
:1;;'1 (; 21.00
Sewage System 0
SQ. FT. :;; BDRMS
"
.,..... ..,-
,..".~t~ . ..'
STRUCTURES TO BE BUILT THIS PERMIT
l~G"J
",.,..,....
"'~ '.-..~.....
')1(; c 5.3)
~! ,,')I,;:
SEWAGE DISPOSAL
PUBLIC 0
BUILDING
WASTE DISPOSAL
PLUMBING
PLAN REVIEW
PARK TRAILER
1-1..",.., '.:1:"
, J....
TOTAL
.
fEES
PLUMBING INSTALLED BY
OWNER 0 OTHER: NAME
WATER SUPPLY
SEPTIC TANK 0
OTHERD
~21a(2
(if)_r~
~'i..~~
o OTHER
PUBLIC 0
~ ar:~
t, ~:p..tn
COUNTY BUILDING & SANITATION SPECIFICATIONS
MIN. SEPTIC TANK CAPACITY
WITH DIST. BOX, GAl.
DRAIN fiELD REQUIRED
1,,,
..~
!1r.:'V:l ~..
TRENCH WIDTH FT. .... OR SQ. FT.
;,.....:..-
L1N. FT
TYPE OF STRUCTURE
!~:r-\
~..
OCCUPANCY
i C', J
ZONE
PUBLIC UTIl. EASEMENT
BLDG. SETBACKS __ FT. fROM CTR. OF ROAD RIGHT Of WAY
(~~ ,n,
fRONT ~ SIDE INT...J SIDE EXT.
AUTHORIZED SIGNATURE - DATE
i~./ J. :::. I ,~:~ ~JV :.. ;~"~::t.Ci;J
REAR
2J~
USE CLASSIFICATION
~f~:::: ~:#"C'J:(/Cn.=:~t'^~t~~
BLDG. PERMIT - WHITE
OFFICE COPY - WHITE
COUNTY TAX - PINK
PLUMBING - CANARY
BUILDING - GREEN
SANITATION - GOLDENROD
IMPORTANT:
,ORM:: C55-1)
(POST THIS PERMIT ON MAIN BLDG. AT SITE)
LANE COUNTY, DEPT. Of ENVIRONMENTAL MANAGEMENT
COURTHOUSE ANNEX, 135 EAST 6th, EUGENE, OREGON 97401
'1.<;,
PHONE
I
PHONE
New System 0
VALUATION ~
2!.~ ',:::.~'~'
~ _ ~-.~~', _ _e~.
<"""" :__.,'0-"- ~-,,,
~" ; ~'!t.../ '.
DATE
;:jwto
,'H
'"
"-
,
SLAB FLOOR
PLUMBING GROUNDWORK
.
.
, ,
i
,
ApPROVED r7 OISAPPRQVED Cl DATE
INSPECTOR
REMARKS
GAS PIPING GROUNDWORK
ApPROVED / / OISAPPROVEO Cl DATE
INSPECTOR
REMARKS
ROUGH PLUMB I NG
DATE y/Z -/5' INSPECTOR ~~
ApPROVED ~ DISAPPROVED Cl
REMARKS
ROUGH GAS PIPING
ApPROVED Cl DISAPPROVED Cl DATE
INSPECTOR
REMARK 5
FINAL PLUMBING
ApPROVEO l!?:J D,SAPPROVEO Cl DAT~ -~c>'7' INSPECT6Rc...--y~
V
REMARKS
FINAL GAS PIPING
ApPROVED Cl DISAPPROVED Cl DATE
INSPECTOR
REMARKS
CERTIFICATE OF OCCUPANCY
READY TO ISSUE r7 NOT READY TO ISSUE / / DATE
INSPECTOR
REMARKS
INSTALLER:
Complete
PROPOSE.WAGE OISPOSAL SYSTEM RECORO .
top part of for signature and submit both cop with application.
PERMIT NO.
311-7"
(~ G.
.
INSTALLER'S NAME
~A~OALL..15
No. Living Units
I
Septic Tank:
Ft, from we'350 Steel 0 Concrete ~ No. Compartments \ Gal. Capacl ty (COO
Inside Oimensions: Ft. Tile Oisposal Field: ~
Lenqth f1'l Width c;- Oiameter Oepth r;- Distribution Box: Yes I Nil"
~~~R '12n55 ()\JEJZ.u.OI-6E1Z Other Distribution-Type ~-EeII1L
""2 L t"'J /l Feet from a..o rn
HAILING .JO':)C.l1 Or"lTlNE f?O WEll d~' Foundation";)'-'
ADDRESS GOil1'}65 Gf?L~vE Oe. ~~~n~ine lOOT Side (00+ Rear 1001-
Length of Lines-Ft. [TrenCh I Total Sq. I Ft. Between IFiller" IFiller Depth IFiller Below
IJCll2\o03)O:>4Ito5. 6. Width"Z./ Ft. 9lOo Lines 10' Tvpe \1~Above Tile<-inJrile bin.
'lot Plan (see instructions):
PROPERTY ADDRESS
\-l-ot 6 S:lZV ,
Bedrooms Baths
~ '?.
~OWE,1-L
Basement
Yf'!5 tNO)
~
'\?o.
Water Supply
P'.'~l ic Other-List 111EI..L..
-l-VWELL
~D
,
I','
/,
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'5\'1'~ U!:;
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'To Tt:eE:l1uli?m.. RD
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.
RECEIVEJ
By
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, ~Iope. ,
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I
AUGO'(197~
LANE COUNTY
ENVIRONMENTAL MGMT.
rJ /' (\ n (l ')/}
Date PI- (,,-7Z;- Si~nature,~ .rt<9y. /'r1 AI( 1l../Vl.IJt./IJ UI/
CERTIFICATE OF SATISFACTORY COMPLETION ~
For Sanitarian Use Only: Dat~: 8-.11- 'J?
In accordance with 1973 Oregon Laws Chapter 835. Section 214 this certificate is issued
as evidence of satisfactory completion of a subsurface sewage disposal system at the above
loct:1.
Approved: System Installation conforms to current standards
Disapproved: Does not conform to current standards
Remarks:
C55-11
,d1J.~
S~nitarian's S~nature
LANE COUNTY
STATE OF OREGON DEPARTMENT OF ENVIRONMENTAL QUALITY
,NOTE:
,
NO PERMarLL BE ISSUED UNTIL THIS APP.ION HAS
APPLICATION FOR:
PERMIT lF~ '\ \ -'1s:
BEEN APPROVED
Ii'
CJ
CONSTRUCTION ~ MOBILE HOME
OWNER ~""J-.J...J.......
CJ
PLAN REVIEW CJ
CIUU;GE OF OCCUPANCY CJ
Name Address City Zip Phone
CR CONTRACTOR \<e.. e""'''' ""\- I?:,\l" , \(-,qO S, "A".s+ Sr.>\. L-l. O'<r 71./ b -4 L/ ;;) C;
Name Address City Zip Phone
O,S, REG, U I, \ I.,
\1 Range....... ~ ~13-3 ~c) Census Tract ~~
Twp, Section Tax Lot Code
Subdivision V -I! "- 0.. \::) oJ. (L,_ Lot ,~ Block \ Property Acreage Width______Depth
ACCESS TO PROPERTY (Road Name) \::).. \ '0. to <. ~ \-:)l)(> -l '^-"--'
Existing Structures on Property: /
\ Property Location - AddreSS/Directions:~'1:) q
'\ - )
r Below fa r Of f ice Use On! vXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
>--- (\'...( Sq, Fe, ........ UBed~........ Valyation
~~ ~ \-.<> <:::J ~',,",COI - \ ,f'\..... ""' \\~>\ ~ )<::J\.P{,)~ ;:-~\..I.'1~ \.::\{)
. ~_ "'" '\:::.>--- ~ ',,- S\l ~ (Ii)) ""~ '- ri.' l\":\I.\. RC
l)" l\7n<;.p
~1)P\.-'\I'"
n.~
l.
SEWAGE DISPOSAL, .ACl\-t -.... {
S~ Inspection U L)"\. \ 0<. \.
WATER SUPPLY: '
Well Spring
Other
Exi~ting Sewage Disposal System
Public CJ
Community ~
CJ
or New System ReqUi~ ~
Name of Community or Public System
FEES:
BIdg,
Waste Diep.
Plumbing
Plan Review
Mobile Home
1% Surcharge
\.:;;2 \ ,00
c:...~~
'-~.
- '\=1-, ( I-... ()
PLUMBING,
Installed by Owner
CJ
Other CJ Name
PL}ll'BlNG If.E~
'--\~0~ of
Fixtures
\.~ Sewage
Connection
j.., Water
\:;l Connection
TOTAL
PLANS FURNISHED FACILITY PERMIT
\. ~~, r-1 A rlL,
. ">\ L---.j C SH W YES CJ NO c::J YES CJ NO
ih~a.'Q..,oo t...Ud ~K~\.(J''103 XSignature of ArJR!!::.ant:..J:1,.<JoLO~=-- %, \f2o _\ -"'
. \ Fee Received By:.i.. --....."'-., ~ Date: ~ \.:::.
Min. Septic Tank Capacity
ClOD
Drainfield Required - Lineal Feet: ;:((:)
'.10'(
Maximum Depth ~
f
Type of Construction (:,f) LY
Group Iq V Fire Zone
Use Classification
Bldg Setbacks - from Center of Road Right of Way:
.......... ' D'
Front ~ Side Int. / SiQa...i"".,
I
Rear? 6
Zone Ae.r
~T ~/f7.<'
DATE:
1i~T}: ~ IJ tl!:UJING: // ../) /DATE:
~/4, /7S fl1.5r"h1fJ /~.!5:;/,;.h f)~l:~
E~IRO~NTAL aNAGEMENT / -
C55-11
~:
LANE COUNTY DEPARTMENT OF