HomeMy WebLinkAboutBuilding Miscellaneous 1995-6-27
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91') 95 MUST BE IN BLACK INK
Permit No. ~ 0 :- Twnshp. I 7 Range ('):3
Standard System)l( Alternative System [J (Spe,cjfy Type)
Job Location (Street Address) J 74:1. ,t..).alr-"~_ Sf
SupdivisionlPartition # Parcel
Section .;l'l
torm S5S.11
Tax Lot51l'
SD",...d"'~IJ(,
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. Lot
Block
DErAIL SYSTEM PLOT PLAN AS CONSTRUCTED
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b'.IHUNME.I<lTALH~L' .'
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USE BLACK INK ONLY
FOR INSTALLER'S USE: Trench Deplh Gravel Depth Below Tilp
Tank Capacity Manufacturer
Measured Distance from Well to Tank From Drainfield Total Length of Lines
COMPLETE THE FOLLOWING IF A PUMP WAS USED ON THIS INSTALLATION:
I (installer's name) certify that a (Mfg.l, (Model No.) Pump
and Mercury Float Switch (Mfg. and No.) nave been installed wilh this sewage installation.
Signaturp "' Datp
,
.
FOR SANITARIAN'S USE ONLY:
COMMENTS:
!il"System Approved
o System Disapproved
o Needs Correction
System Capacity /.I-5u
~tem Corrected
gaL/day Signature .~--~
Datp
Date "-.l7-'i~
INSTALLATION RECORD & CERTIFICATE OF SATISFACTORY COMPLETION When signed 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 all three (3) copies 01 this form to: Lane County Environmental Health Services. located in the basement of the
Public Service Building. 125 E. 8th Avenue. Eugene. OR 97401.