HomeMy WebLinkAboutMiscellaneous Plans 1981-2-4
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VICINITY MAP
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MA.LLARD OIZ.
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':LAN1IN40 Ave
Installer f1 <<J Pol!.~' tJ .(f'1V\.Fh,~;o-
Tahone ~iq?~~~~en~l
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Bonding Company
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1~lQnature of licenseel .
If Installed By Owner-
Datp
(SignatureolOwner}
Applicant's Name & Address
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tf.!:.\> G>tm. Eu_ t:.~.
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form c55-11
Tax Lot ~V~... 2.~o
rJA MUST BE IN BLACK INK
PermitNo.3J/}~~Cl"UTwnshP. 1/ Range. J<)..~ Section-2::l./..3
Standard System I!'I" Alternative System 0 ISpecify Type)
Job Location (Street Address) ~ c;o G,,,,... h,,_ 12 Ad)} .
Subdiv' . tition #
~ . /,Sy \:t& ~M PLOT PLAN AS CON..>> & ....UCTED
fJ[Cf!/;~' .. Scale J " 40'
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~\ t;;;'.;;:.:,! - / / Church BId<;. CO""?le1f /
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71' / ,,/~' -"- - - -__
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ElC/~1 Oro/nriel./ f Srr"d..r4$
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Parcel
Lot
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UM Ip.A9,S INK ONLY //
FOR INSTALLE~~~SE: d Trench Depth .'" f-> Gravel Deptl}..j3elow Tilp 6
Tank Capacity, b a cJ Manufacturer (~Tl i"O r-~, ,. k t".n ,(5 0,," v.II;~
Measured Distance fronfWell to Tank.JI\." UJelL From Drainfielrl I-uo ........~I Total Length of Line<
COMPLETE THE FOLLOWING IF A PUMP WAS USED ON THIS INSTALLATION:
I (installer's name! certify that a IMf"'1
and Mercury Float Switch IMfg. and No.),
Signatur~-~./ AIf2. L_- '_/
,.. ........--
FOR SANITARIAN'S USE ONLY: ~ystem Approved
COMMENTS:
~P7
(Model No.! Pump
have been installed with this sewage installation.
Datp ':</.f'/!?/
o System Disapprov,ed
o Needs Correction
- ~~,. O~ Corrected Datp ~ -4 ?/ii:.
System Capacity gal./day Sign~.ftol'r1'~L.~".....~ DatP~'~;' ~
INSTALLATION RECORD & CERTIFICATE OF SATISFACTORY COMPL~ION When signed by the County Sanitarian, this certificate is
evidence as per GRS 454.665 of satisfactory completion of a subsurface sewage disposal system at the above location.
'Heturn tnlS torm to: t:lullalng ana ~anltatlon LJIV., LJept. at tnvlronmental Management, locatea In tne basement 01 tne
Public Service Building. 125 E. 8th Avenue, Eugene 97401.