HomeMy WebLinkAboutBuilding Miscellaneous 1984-12-10
t--O,~NSR'S N~ AND ADDRESS
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STATE
OWNER'S TELePHONE fl
77/7'-#8
TE:lliPHO"...E NUHBER
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I understand that the information containCd~. this report signifies the ce,ndition of the water
en the date of investigation only. ~
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APPLICANT,~./"F (~lease print) APP\.k:ANT'S SIGNATURE DATE
8,iJ it ;9d93 .... cf'Lj
supply
Do.,.ner
o Agent
o Buyer
o COMMUNITY WATER SYSTEM (name):
~INDIVIDUAL WATER SUPPLY:
r Inspection
Requested
Construction 0
Bacteria ~
Arsenic []
o Approved
o Not Approved
Complies with
Accepted Standards
Does Not Comply
(see comments)
.
o
~
o
o
o
o
o PLOT PLAN ATTACHED
o INS1~EC:~:~ C::~:LIST: ~~ ~~1:;1~, ~~~ 'Zf;
2. Sanitary seal present? 0 Yes 0 No
3. Height of well casing above ground:
4. Is there a proper vent and screen on well? 0 Yes [] No
5. If a spring or other surface supply, is it properly developed and protected from
sources of pollution? 0 Yes 0 No
6. Is there a well log available? 0 Yes - Include with report. 0 No - Indicate
presence of seal material and type:
7. Is the water supply treated; i.e., chlorination or filtration? 0 Yes 0 No
If yes, describe and note that same must be of raw water (before treatment):
8. Is the water supply located in any geographic area where the presence of the items
listed is suspected? Check those that are present: 0 Arsenic 0 Salt 0 Sulphur
o Quantity limited.
If any of the items above are present, have tests been conducted? [] Yes [] No
Date of tests:
Results of tests:
COMMENTS:
/;2..-/0-f'L(
Date of On-Site Investigation
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LANE COUNTY DEPARTMENT OF PLANNING & COMMU
125 East Eighth Avenue, Eugene, Oregon
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LANE COUNTY DEPT ENV MGT RECEIPT ~
APPLICANT MCCULLOCH. ROBERT ADDR 820 FILBERT LANE,
.JL~ 1802061100300 SUBDIV
~EW BLDG TYPE USE R BDRMS 0 UNITS 001 STORIES ~BLDGS
OWNER NME ADDR
.. CODE APPL NO ACTION DESCRIPTION . SQ FT UNIT COST VALUATION
'WElP
BP
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MECH
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LRR
329384 DATE 12048"-
SPRINGFIELD. OREGON
LOT BLK
001 PHONE 747 6820 .
l1 ...
FEE DAY".
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~ FIXTURES,
FT. WTR,
MECHANICAL FEE
STATE SURCHARGE
PLAN CHECK FEE
SWR:
LC 329384 WELL
APP
1
BY RLH
FP
SDS
SI
RA
PCK
2
EST. COMPLETION DATE
FT.
RAIN:
4%
65%
OTH ISS
3
TOTAL FEE**
FT.
35.00 '
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35.00 CK ~
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