HomeMy WebLinkAboutBuilding Miscellaneous 1978-9-14
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eANNING & COMMUNITY DEVELOPMENT.
ACTIVITY INFORMATION SHEET
lane county
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COMPLETE THIS SECTION. INCOMPLETE FORMS WILL BE REJECTED!
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PERSON MAKING REQUEST
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PROPERTY OWNER
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MAILING ADDRESS
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CITY , STATE
t971/~~
ZI P CODE
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MA I LI NG ADDRESS
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CITY STATt ZIP CODE
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. BUSINESS TELEPHONE #
,/JU, -188?
HOME TELEPHONE #
BUSINESS TELEPHONE # HOME TELEPHONE #
2" PROPERTY ADDRESS slll7lE
(IF DIFFERENT FROM MAILING ADDRESS)
3 MAP & PARCEL NUMBER
(REQUIRED INFORMATION)
(from tax maps in Department of Assessment and Taxation
or from tax statement)
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~ () ~ TOWNSHIP RANGE SECTION
~ 1f6?~ ~ONTIGUOUS PROPERTY IN SAME OWNERSHIP:
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TOWNSHIP RANGE SECTION
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TAX LOT(S) OR PARCEL # tONING
'TOWNSHIP RANGE SECTION
TAX LOT(S) OR PARCEL # ,ZONING
TAX LOT(S) OR PARCEL # ZONING
ACRES
4 SUBDIVISION (if applicable)
LOT
BLOCK
5 REQUEST (state exactly what you plan to do) flLGce I11DIJJU=- A/)~,L; DJV
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6 DIRECTIONS TO SITE: J,;tJV.!J~d~AzL.:"-# a ~~/UV,.a-~.AL~
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r! ' ** FOR STAFr USE ONLY ** f,- , NUMBE~ . il
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ZONE/LAND USE:
BY: DATE:
DATE
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TIME IN:
OUT:
, 'WATER SUPPLY SYSTEM REVIEW ,
Permit # .)170 -?~
lane county
The following information has been forwarded to the permit
processing section. If there are any questions regarding
the information below contact Lane County Environmental
Health, 125 E. 8th Avenue, Eugcne, OR 9740l 687-4051
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o COMMUNITY WATER SUPPLY
A. 0 Approved
[] No knowledge of indicated public or community water supply system
'C=J Pending approval due to hnprovements being made
c=J Not approved
c=J Provisional approval .
B. 0 Within water district
[] Not within water district indicated, check with Boundary Conunission
[] Water District cannot extend services to this parcel at this time
C. [] System not adequate for more services without improvements
[] Existing connection
~. INDIVIDUAL WATER SUPPLY
A. ~permit on file
[] No permit on file; permit required before installation from
Environmental Health
B. [] Spring or surfac~ater supply needs variance approval
C. [J Existing water supply not connected
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[] Existing connection to water supply
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Comments:
Environmental Health
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Date
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