HomeMy WebLinkAboutPermit Sewer Connection Record 1980-10-3
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Job location (Street, mile pnC"'} '1 /~ /?/1,1f-f/~ 5"T .5/'7 L/
~Ubdivision4Af-.r.-.)f1ZI:: jI) ,PI --17"T "";:: tA/ II- I-; }/1?-IJT5 lotll-f-/'2. Block L2...
FOR SANITARIAN'S USE ON l Y: D System Approved D System Disapproved )&l ~eeds Correction
COMMENTS: 7.&. SjI5!.'" ;,d..I/.P is ~1""f..e (&. f/,. eJc...hj O,? 6J~~-"~,
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Signature: ~~./ Dat.0-.v..,l'O
FOR INSTAllER'S USE: Trench Depth.:3'" -J" Filler Depth Below Tile ~ -/6 -
Tank Capacity. /~ Manufacturer E""'t//.-Fh""- <4/V,l)
Measured distance to well from tank --.i:""/J - from drainfield 7/J-
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INSTAllATION RECORD AND CERTIFICATE OF SATISFACTORY COMPLETION
When signed by the County Sanitarian, this certificate is evidence as per ORS 454.665 of sat-
isfactory completion of a subsurface sewage disposal system at the above location.
Return this form to: Permit Processing Section, Department of Environmental Management,
Public Service Building, 125 East 8th Avenue, Eugene 97401
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CONSTRUCTION/PLACEMENf"
PERMIT
FOR OFFICE USE ONLY
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Application! _,. "':"r7:" (: .'~.
Permit # L( , /./( "to,.', ,
o Two Copies of Plans
GfTWo Copies of Plot Plans
[]Mechanical Checklist
[JPlumbing Checklist
I [JPlan Check Info Sheet
COMPLETE THIS BLOCK.
PLEASE USE BLACK INK AND PRINT.
I SECTION TAX LOT DOUT OF
02,Z ~ 17'00
(. '-( I r. . . '-,. I LOT/PARCEL I BLOCK
U~ _ u;....\U'_:('-.. ~ ...., )
lAo..., t',j 'J II 1-' It.. 1:0.-
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:-)tt( OQ:t ,":-3 p)\cI.
CURRENTLY ON P~UPERTY '~
) (1(UU}()V j ~ '~J! led.
DESCRIPTION OF PROPOS~WORK J
. I-\.J I)ClIK.. ...Ot:LDCl ~ dl~)).)~'3a.L :,::::>:. :(>tf1Jin
If OF BEUROOMS III OF STORIES -.-J I # OF tMPLOYEES I
i 6' -(;3-
OWNER'S NAME AND ADDRESS .
\;~ l LIL. (I~ lor 2/0 Borrt).
C~_~lTRAC~~' S NAl-JE ANQ ADDRE~..:J ~, ,,(...., _ _
\ '1l I t">Oud. I >VIulJ(ldo .....Dn..lt.
CON"I'3RACTO, R~ os..... l...JDlRE3~N~-'-';..~ITE t
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I HAVE CAREFULLY EXMINED THE COMPLETED APPLICATION FOR PERMIT, and do hereby certify thilt all infQlolMtion hcr('on is true ilnd correct and 1 furtller
certify that any and all work performed shall be done in accordance with the Ordinances of Lane County and the Laws of the SUIte of Orc<jol1 Jlct-laininq
to the work described herein, and that NO OCCUPANCY will be made of any structure without the permission of the Building Division. I further certif}'
that. registration with the Builder's Board is in full force and effect as required by ORS 701.055, that if exempt the basis for exemption is noted
hereon. and that only subcontractors and employees who are in compliance with ORS 701.055 will be used on this project. I HAVE REAO AND CIlECY.ED THIS
APPLICATION THOROUGHLY.
In
RANGE
O~
TOI-mSHIP
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SUBDIVISION/PARTITION (it applicable)
(\n'\ r "ci..rdo 01 a.-.H oL
If STREET
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LOCATION ADDRESS
ZIC
STRUCTURES
1)u.,t' I tLn,(
CITY
ZIP
PROPOSED USE OF PROPERTY
ua~esidential [Jlndustrial
o Commercial
Dpublic
I $
VALUE
~u
(')\1
WATER SUPPLY 0 Proposed
LL:l21l 0'Existing
TELEPHONE NUMBER
C'if. -oV:><.d '74 7- t?-n ;;J..
:3 ." J '? 3 - TELEPHONE Nur-mER II
( . {1!'- (-",,1 n ~-<rl. I). Vi . ~ (:4h- ~1'~";(1
~f")5rl -f!'l "G10r r; ,) 3\0 4 10 ( ~)
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NAME (pl~ase print)
1'2 J.f' ; ;;d~<-/
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SIGNATURE!
/0 --3 -.J'U
DATE
DOwner
--
[!}Contractor
o Agent
-'
m'PLANNING/ZONING: Zone
RA
Parti bon #
eL, side
Parcel #
Parcel
size \ . ")CJ
o.r~\ fj
,
:f
r-linimum Setbacks:
C
L, front
interior
rear
Comments: \.'1rl'.t t
, '"\"><
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.:1/ \,1.+/1'1"n
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Date:
10-3-30
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o FLOODPLAIN:
o RURAL ADDRESSING:
IiZISANITATION:
In flood hazard area?
o No
[] Yes, see attached sheet.
Date:
GRID COORDINATE
N
E
Date:
Installation
Spcci fications:
Gilllon
Tank
B. P. . t-JO i~mrrt
300
lns~allation Record Issued? [] Yes [] No
S. 1. # jA<F:-;}-)
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fIt" j
Lineal Feet
of Drainfield
.f'/
Maximum Depth
of Trenches
Comments:
7:'0::.'
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1- 1'..1
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Date:
.70Jrr)
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o PLANS EXAMINATION:
Type
Group
Use
Comments:
Date:
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CONSTRUCTION AUTHORIZED BY THIS PER}lIT
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Description
r~' \ l' I . (
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Fixed Fee/ Floodplain Fee $
Sq. Ft. Unit Cost Subsurface Fees $ 7:-\ ,(}{)
Building ,,/
Fee $
Sewer/Storm Drain/Water $
Plumbing Fixtures $
Mechanical $
Plans Check Fee $
State Surcharge $
TOTAL FEE $ ,/,F{;"D
TOTAL VALUATION $
FEES PAID BY: ~ Check 0 Cash
By: (h rrrl'
Date: 10 -;') -;Y-J
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PERMIT APPRO~D BY BUILDING OFFICIAL/DESIGNEE (per ORS 456.805(1)) DATE
LAN~~COVN~Y DEPARTMENT OF ENVIRONMENTAL MANAGEMENT / 125 EAST EIGHTH AVENUE, EUGENE, OREGON 97401
C74-194
SEE REVERSE
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SETBACKS ANO OTHER CONDITIONS OF APPROVAL MUST BE STRICTLY OBSERVEO. VIOLATION CAN RESULT IN REVOCATION OF THIS PERMIT, >
CITATION UNDER PROVISIONS OF LANE COUNTY'S INFRACTION OROINANCE, AND/OR OTHER REMEDIES ALLOWEO BY LAW.
WHEN READY FOR INSPECTION CALL 6B7-4065. A MINIMUM OF AT LEAST 24 HOUR ADVANCE NOTICE FOR INSPECTION REQUEST MUST BE
GIVEN. Have the following information ready: Permit number, job address, type of inspection, when it will be ready,
your name and phone number, and any special directions to site.
BUILDING OIVISION:
REOUIRED JlISPECTIONS
1) FOUNDATION INSPECTION: To be made after trenches are excavated and forms erected and when all materials for the foundation
are delivered on the job. Where concrete from a central mixing plant (corrmonly termed lltransit m;xedtl) is to be used,
materials need not be on the job.
2) CONCRETE SLAB OR UNDER-FLOOR INSPECTION: To be made after all in-slab or under-floor building service equipment,
conduit, piping accessories and other ancillary equipment items are in place but before any concrete is. poured
or floor sheathing installed, including the subfloor.
3) FRAMING & INSULATION INSPECTIONS: To be made after the roof, all framing, fire blocking and bracing are in place and
all pipes, fireplaces and chimneys and vents are complete and all rough electrical and plumbing are approved. All
wall insulation and vapor barrier are in place.
4) LATH AND/OR GYPSUM BOARD INSPECTION: To be made after all lathing and gypsum board, interior and exterior, is in place
but before any plastering is applied or before gypsum board joints and fasteners are taped and finished.
5) FINAL INSPECTION: To be made after the building is complete and before occupancy.
APPROVAL REQUIRED. No work shall be done on any part of the building or structure beyond the point indicated in each
successive inspection without first obtaining the approval of the.building official. Such approval shall be given only
after an inspection shall have been made of each successive step in the construction as indicated by each of the inspections
required.
NOTE: All building permits require inspections for the work authorized, such as but not limited to:
A. BLOCK WALL: To be made after reinforcing is in place, but before any grout is poured. This inspection is
required for each bond beam pour. There will be no approval until the plumbing and electrical inspections
have been made and approved.
B. IIOOD STOVE: To be made after completion of m",onrv (if applicable) and when installation is comnlete.
Installation sha 11 be in accordance with an approved nationally recognized testlng agency and the manu-
facturerls installation instructions.
C. MOBILE HOME: An inspection is required after the mobile home is connected to an approved sewer or septic
system for: setback requirements, blocking, footing connection, tiedowns, skirting, and plumbing
connections.
(1) Footings and piers to comply with State foundation requirements for mobile homes or as recommende~
by the manufacturer.
(2) Mobile home minimum finish floor elevation shall be certified when required by a floodplain
management letter.
(3) Mobile home tiedowns, when required, and skirting shall be installed and ready for inspection
within at least 30 days after occupancy. Tiedowns and skirting shall be installed per enclosure.
D. SWIMMING POOL: Below grade when steel is in place and before cnncrete is poured. Above grade when pool
is installed.
APPROVED PLANS MUST BE ON THE JOB SITE AT ALL TIMES DURING WORKING HOURS. THIS PERMIT WILL EXPIRE IF WORK DOES NOT BEGIN
WITHIN 180 DAYS, OR IF WORK IS SUSPENDEO OR ABANDON EO FOR MORE THAN 180 DAYS. SUSPENSION OR REVOCATION MAY OCCUR IF THIS
PE~~IT WAS ISSUED ON THE BASIS OF INCOMPLETE OR ERRONEOUS INFORMATION.
ANYONE PROCEEDING PAST THE POINT OF REQUIRED INSPECTIONS WILL DO SO AT HIS OWN RISK
SUBSURFACE AND ALTERNATIVE SEWAGE DISPOSAL SYSTEMS
(1)
(2)
Permits shall be effective for one year from the date of issuance.
Upon completing the construction for which a permit has been issued the permit holder shall notify.the
Department by submitting the installation record form. The Department shall inspect ~he constructlon ~o
detennine if it complies with the rules contained in this division. If the constructlon does complY".l1th
such rules, the Department shall issue a certificate of satisfactory completion. to the permit holder. If the
construction does not comply with such rules, the Department shall notify the permit holder and shall require
satisfactory completion before issuing the certificate. Failure to meet the requirements fo~ satisfactory
completion within a reasonable time constitutes a violation of ORS 454.605 to 454.745 and th,S rule.
Setbacks - Subsurface SewaQe Disposal
From: Interior property lines
Edge of road right-of-way
Building foundation
Wells. other water sources
Septic Tank
10'
10'
5'
50'
Drainfield
10'
10'
10'
100'
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INS P E C T ION R E COR D FIE L DCA R D
TOWNSHIP RANGE SECTION TAX LOT I
_ /); 03 0';;,;) /7(jO
SUBDIVISION/PARTITION LOT/PARCEL /f'llIOl BLOCK
c L/JA">-oIf1~~ r.P'r- 1/ 0/ f/J,"#&.-YY">P/h ~
mINER'S NAME AND SITEv ADDRESS U nf'~~,' v
c,,7/(j .A~~ ~ nWd
CONTRACTDR"S NAME AND ADDRESS ,. &i/ ~
~"??J,a.~ 'UU""~lA,fi/
I # PLUMBING FIXTURES I # EMPLOYEES
Serial )(?6~
SDS INSTALLATION . ---- t7
SPECIFICATIDN: KtX) Gallon Tank
~ Ln. ft. Drainfield
~ Max. trench depth
New _ Repair X- Alteration _
# BEDROOMS
PERMIT NUMBER
..17tf.. 7.?O
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TELEPHONE NUMBER
7</7- 5939
TELEPHONE NUMBER f
7"';1., .'\,<JS'Y
WATER SUPPLY
MINIMU~l SETBACK
P-EQUIREr1ENTS:
CL, front
CL, side
Interior
DIRECTIONS TO SITE ~rU \S/- /;'" ~A I~I?/../ ?iJ ~ ...-1- ~./~ ~ v'I'/,y1-
INSPECTION TYPE
APV/DISAPV DATE INSPECTOR
REMARKS
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Permit 1/
Permit II
Permit 1/
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Permit II
Permit 1/
Permit II
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