HomeMy WebLinkAboutPermit Building 1974-3-20
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LANE COUNTY .LDING PERMIT OR MOBILE
BUllDINGli!9: MH 0
MAILING ADDRESS
HOM_E PERMIT
PERMIT NO,
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PROPERTY OW,~ER
?.-rr is!.. GLry l.
CONTRACTOR
S.-r.:c
PROPERTY LOCATION - INCLUDE POST OFFICE
j\bovu
PROPERTY LEGAL DESCRIPTION - ME~~S~OUNDS.././
i1.-n-lll i n9 !1 crcs I?I:.f -I /'-1-/
TWP RANGE SECTION
21::0 n. 19th St.
MAILING ADDRESS
S')rinr<'iclcl. Or:'t"on
TAX LOT NO.
CODE
CENSUS TRACT
17
....... ,. 1L
-' .
;(~.;l.1
1ii!!!Ji6. 38'1> I 19-0l
EXISTING STRUCTURES ON PROPERTY
n~ollrn~ end CQroort
LEGAL ACCESS TO PROPERTY
Iqth StrcClt
PROPERTY SIZE - FT.
03
APPL.
NAME
&
MAILING
AOORESS
FOR MOBilE HOME PERMITS ONLY
No, of Bedrooms
Gcry l. Purr ish
WIDTH
DEPTH
AREA
Connect to Existing Sewage System D
TYPE CONSTRUCTION SQ. FT. :it BCRMS
STRUCTURES TO BE BUILT THIS PERMIT
;:~i":>ort cUClvcrtccl into Steru"€;
~6o (~ t\
SEWAGE DISPOSAL
PUBLIC 0
BUilDING
WASTE DISPOSAL
PLUMBING
PLAN REVIEW
PARK TRAILER
Pei1;' 1 ~:~, fC:J
TOTAL
PLUMBING INSTALLED BY
SEPTIC TANK 0 OTHERD
. U.OO
FEES
OWNER 0 OTHER, NAME
WATER SUPPLY
PUBLIC 0
o OTHER
8.00
. 16.00
COUNTY BUILDING & SANITATION SPECIFICATIONS
DRAIN FiElD REQUIRED
MIN. SEPTIC TANK CAPACITY
WITH OIST. BOX: GAl.
L1N. FT
TRENCH WIDTH FT.
OR SQ, FT.
.~!nt ...,pl ic.-:bic:
TYPE OF STRUCTURE
OCCUPANCY
ZONE
PUBLIC UTIL. EASEMENT
5-~J J
BLDG. SETBACKS._ FT. FROM CTR. OF ROAD RIGHT OF WAY USE CLASSIFICATION
SIDE INT. SIDE EXT.
AUTHORIZED SIGNATURE - DATE
hi J.E. ['ons ";y C. I-L'rb~u:t:~
FRONT
REAR
BLDG, PERMIT - WHITE
OFFICE COPY - WHITE
COUNTY TAX - PINK
PLUMBING - CANARY
BUILDING - GREEN
SANITATION - GOLDENROD
,
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--.,
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PHONE
jl.~J~i;":'.1t.:,
PHONE
New System 0
VALUATION
7'0
DATE
~,-?~_7.'~ 51:'
Call 6B7-4065 to schedule all required inspections, All construc-
tion shall comply with Uniform Building Code, D.E,Q. standards
IMPORTANT: for subsurface sewage disposal and county regulations covering
plumbing. All buildings require a certificate of occupancy before
being occupied,
(See Details on Reverse Side)
FORM:: C55-1)
,
(POST THIS PERMIT ON MAIN BLDG. AT SITE)
LANE COUNTY. OEPT, OF ENVIRONMENTAL MANAGEMENT
COURTHOUSE ANNEX. 13S EAST 6th. EUGENE, OREGON 97401
'J
DUILUINu ~llt tVALUATION
}; S,/ C. H-I
395-7tJ
T-L2R Os S ;;(t:),.l,tAX
CENSU~ACT .
b /I'" Ares
APPLlCA T: Q ~ '. J'
NAME I Cirri Sf...,
AODRESS
LOT :20v0
t.,; .
1>( Bl>i id.irrg Permit Appl icat ion No.
..
() Site Inspect ion
() Pre-Permit Investigation
PHONE
DATE
S-,2/-7Lf
--'--' -
L/\NE COUNTY PLANNING DEPARTMENT NOT NO YES
app, icable -
i. Zoning Ordinance Compl iance F () ( )
(Zone )
2. Subdivision Ordinance Comp I i an ce I) () ( )
, Required Access \\ ( ) ( )
.).
4. Building Site (Area, Width, ( ) ( )
Frontage, Setback)
5. Other (see comments) ( ) ( ) ( )
COMMENTS:
NAME
DinE
~;K
.-. ,..,
,.3- ;<S"-7 II
~
- -'
BU I LD ING INSPECTION SECTION NOT NO YES NAME DATE
app) "cab I e
6. Plans Subm i tted ( ) ( ) ( )
7. So i) Stab i I i ty (foot ings) ) ( ) ( )
8. Flood Plain ( ) ( ) ( ) (fll~
9. Other (see Comments) ( ) ( ) ( ) 'J-~8'-7t/
COMMENTS: I ,
--
SANITATiON SECTION NOT NO YES NAME DATE
app I icab I e A I'f'rT"'2. ev-.-e... @.~
10. Sewage Disposal (\ ) ( ) ( )
II. Usable Area ( ) ( ) ( )
12. Water Supply ( ) ( ) ( )
13. o t he r (see Comments) (I' ( ) ( )
--------,-
COMMENTS:
TO APPLICANT:
Your
3- z.,t ~f fr
( )
( )
( )
Building Permit / Site Inspection:
Can be approved.
Cannot be approved at this time as indicated on item NO. above.
Questions and further information on items I through 5 contact the Lane-
COUNTY PLANN ING DEPARTMENT. Ques I. ions and further i nformat ion on items 6
through 13 contact the Lane Coullly Buildinq <<:Jo Sanitation Division.
Wi 11 be held in this office unt i I you can resolve I'he problems iodicated.
Is being returned.
Your bui ldin~ permit appl iCilt ion fee is lJeing returned under separate culler.
["Nt' COIIN'IY I'/.IINN ING OEP/IRTMENT
1:l5' Si;<tlo Avellue [^st, [uyelle, ll'''9"n 971,01
I'llllNt: ~1j2.. 1:111 0 I, 211
LANE COUNTY aUILDING & SANITATION DIVISION
135" Sixth t-lvl;1'uc East, E"9cll". Ol(."gon 97401
I' 11L1 N I : J.lj2-1311 flIT. ~1I
1155-=28--'- -----
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LANE' COUNTY
BUllOIN.G)'@
.LDING PERMIT OR MOBILE
MH 0 I
MAILING ADDRESS
HOME4lE PERMIT
(
PERMIT NO_
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3~.74
PROPEII:TY OWNER ....
Porrlnh..-Ollry I..
CONTRACTOR
5 Cl::C
2130 ~. 19th St.
MAILING ADDR~SS
SDrlROflold. OrenDn
PHONE
'q7.CIIIlfI
PHONE
1
PROPERTY LOCA liON - INCLUDE POST OFFICE
.Above
PROPERTY LEGAL DESCRIPTION - METES, BOUNDS
1\cm~llno Acres
TWP
RANGE
SECTION
TAX LOT NO.
CODE
CENSUS TRACT
17
03
2$.2.1
2Cl!n
I~G1_
EXISTING STRUCTURES ON PROPERTY
~lllnn end COrDort
LEGAL ACCESS TO PROPERTY
APPL.
NAME
&
MAILING
ADDRESS
FOR MOBilE HOME PERMITS ONLY
No. of Bedrooms
Gory L. Parrloh
. ...... . .'
'\~ ...' ,..:......:.-
l!'l.th Stroot
PROPERTY SIZE - FT.
WIDTH
DEPTH
AREA
STRUCTURES TO BE BUILT THIS PERMIT
Connect to Existing Sewage System D. New System 0
TYPE CONSTRUCTION SQ. FT. # BDRMS VALl.!ATION
Cal'j)ort cO:Jvortod Into StCITOI',o
li!(1O 0 f'I nn
... '\t ._'"....
SEWAGE DISPOSAL PLUMBING INSTALLED BY
,
PUBLIC' -0 .
SEPTIC TANK 0 OTHERD
. 6.00
FEES
OWNER 0 OTHER: NAME
WATER SUPPLY
BUILDING
WASTE DISPOSAL
PLUMBING
PLAN REVIEW
PARK TRAILER
Pcnul~y l'c:J
PUBLIC 0
o OTHER
TOTAL
-a. en
$ 10.00
COUNTY
,
BUILDING & .SAN.ITATlON SPECIFICATIONS_ I.
MIN. SEPTIC TANK CAPACITY
WITH DIS1. BOX: GAL.
D~AIN FIELD <REQUIRED
L1N. FT
TRENCH WIDTH FT.
OR SQ. FT.
C!~ Q;ll !cable
"
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,I
,
TYPE OF STRUCTURE
5-tl
OCCUPANCY
J
lONE
PUBLIC UTIl. EASEMENT
\.
BLDG. SETBACKS h FT. FROM CTR. OF ROAD RIGHT OF WAY
FRONT
USE CLASSIFICATION
Inl J.E.
SIDE INT. SIDE EXT.
AUTHORIZED SIGNATURE - DATE
Co06 bv t. NJrbcugh
REAR
DATE
"
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.. '_.,;).', ... . '-'\ .....f I
Call 687-4065 to schedule 011 required inspections, All canstruc-
'. -. tion sholl comply with Uniform Building Code, D,E.Q, standards'
IMPORTANT: for subsurface sewage disposal and county regulations covering
plumbing. All buildings require 0 certificate of occupancy before
being occupied, \
(See .Details on Reverse, Side) .. \'..
!l.lt9-74 !I1~
BLDG. PERMIT - WHITE
OFFICE COPY - WHITE
. COUNTY TAX - PINK
PLUMBING - CANARY
BUILDING - GREEN
SANITATION - GOLDENROD
"
.
(POST THIS PERMIT ON MAIN BLDG. AT SITE)
LANE COUNTY, DEPT. OF ENVIRONMENTAL MANAGEMENT
COURTHOUSE ANNEX, 13S EAST 6th, EUGENE, OREGON 97401
"
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FORM ::= C55-13
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SITE INSPECTION
ApPROVED Cl 01 SAPPROVED Cl DATE
INSPECTOR
REMARKS
FOUNDATION INSPECTION
ApPROVED I
1 01 SAPPRDVED
/ /
,
DATE~
{
INSPECTOR
REMARKS
FRAMING INSPECTION
Cl DATE ~dt
INSPECTOR
ApPROVED / / DISAPPROVED
REMARKS
LATH OR SHEETROCK INSPECTION
ApPROVED I
I DISAPPROVED I
I DATE
INSPECTOR
REMARKS
FINAL INSPECTION ~ ~
ApPROVED ~'SAPPROVED ~ Cl Ao;;TA-J.9-7~NSPECTOReL.-
REMARKS AU-J'-~l-f6 -71/M.-
CERTIFICATE OF OCCUPANCY
:::::K:O ISS~~~ f? DATE
A~nV~ ~~
, ,
Jf5'1t/~~ 2)3D 71. /9~
INSPECTOR
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SUPPLEMENT TO BUILDING P~RMIT ,NO. a<9..<)"~ 7~ .
. Lan~-Co~nty, Oregan ..
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OWNER .1J~ e::<: p~ J
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CONTRACTOR .A /l ~ c ./
PROPERTY ADDRES!' .xl ~ ~
'ria' ADDITION: !
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~ ~ J1J..-d q 0' fl7.J'./I./ 7;-1 -d'Ja'd
. /' V y-
'"77:" fJ/Jfl'7J (l ~ ('/?LA /M1A '7;-( d-tJ y;){) ) ,
~tI/? @!:?,YIJ -' .$!> /,J,/}: to/) =~2.0-
l.l.t..l...L::1f1/J'r"P ...J14.tl/J .,tJO '-U- /I~k~ '"It.'~
C~ANGE RESULTS IN:D REFUND OF F~~ - '1f:,7.;LtJ :~O .=.
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MAILING ADDRESS c::J/3:J :;no
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'17
MAILING ADDRESS
D CORRECTION:
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'""7~_~~-'__' (!C__~~
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8',' 0 r'/ ~"JJ,
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o ADDITIONAL FEE:
BUILDING
SEPTIC TANK
SANITARY CONNECTIONS
8".O~
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CI: -r=-m ::r-
lr.O<:S
~,~'-1 {2~~4j Dat" /I-IS'7~
-- /- - .
TOTAL ~-'':.:,'~
DATE FEE PAID //-/<;"- 7~
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LANE COUNTY DEPT. OF HEALTH & 9,ANITATION
D 0~
Cash ,Check
err
Supplement N2
_ 1831
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LANE COUNTY ~U NG PERMIT OR MOBILE HOME U.APPLlCATION ,/
PERMIT TYPE - BUilDING __ MOBilE HOME DOSC REG. # PERMIT:it: 39 f)- 7v
PROP;JU.Y OWNER .... AILING ADDRESS PHON1:
l-'.Ci>"k\.... \)~'V...,~~ '2-\~O \~O. \C\yl., <;:.+- 'q,-.::>t.c9... 7cf-7-S"3'3c.!-
CONTRACTOR MAILING ADDRESS PHONE ;
I Se. \
PROPERTY lOCATION -INCLUDE POST OFFICE
:2.'">, 0 -N..~., l\.l,,"'-.. S\-.
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AND
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<;. '? 'T .. ,.\<\L~ \~ , O'Y~() 0 ","-,
~h I'Y\. h1 i rvl A- ('tOe. ;;z;.r / ,tU(. /
. SEC. '" '- TAX LOT # 78". CODE
;? h . .r.1? .Q.__~ -6 01 Ol q-03
DESCRIBE EXISTING STRUCTURES ON PROPERT'{,J IF ANY
<;:Vl",\e~ ~Y~~_ "rI"C LAlc...-.,...
LEGAL ACC/;) TO PRrqi--hOAwE. bR #
PROPERTY SIZE-WIDTH DEPTH
METES & BOUNDS 0 YES
ATTACHED 0 NO
PROPERTY LEGAL DESCRIPTION
LOT - BLOCK - SUBDIV.
TWP RANGE
II '3
CENSUS TRACT
\ APPLICANT
NAME
(~Ci '-t\A
,
~~...""~""--
~ c......-\:-
MAILING
ADDRESS
- -fell MOBilE HOME PERMIT ONLY
Number of Bedrooms
STRUr:;;;~~~HIS PE~^~V\ \tf\~ A
q-\-"'- s-L--:
S 1..\:ci.
AREA
~
Connect to Existing
TYPE CONSTRUCTION
~i-'1'lflW.p .
\,J
Sewoge System D or New Sys'em Req, 0
SQ. FT. # BEDROOMS VALUATION
'3t..()GJ 4 --:J = Q 7;< 0
SEWAGE DISPOSAL
PUBLIC 0
BLDG. t'
WASTE 015.
PLUMBING
PLAN REVIEW
SEPTIC TANK 0
<;;;t_-
FEES
OTHER 0
WATER SUPPLY
PUBLIC 0 OTHER
PLUMBING FEES
?Jo ~1!t/~~f~-
OWNER 0 OTHER 0 NAME
PLANS FURNISHED
/' FACILITY PERMIT
_ FIXTURES
/ YES 0
NT:",\ '1
I/'L....,
NO n
DATE
~~\iy fe1'
T'.-
1"6.-
CASH 0 SEWER
CHECK ~ECTlON FEE
J~('\u ~
!PERMIT # /
PUBLIC WATER
CONNECTION FEE
COUNTY BUilDING & SANITATlON'SPECIFICAT\l!5NS
DRAIN FielD REQUIRED /
lIN. FT. TRENCH WIDTH FT. OR SQUARE FEET
"---'
DATE
?'~20-IY
TOTAL
MIN. SEPTIC TANK CAPACITY
WITH DIST. BOX: GAl.
TYPE OF STRUCTURE
6"#
BLDG. SETBACKS - FT. FROM CTR. OF ROAD RIGHT OF WAY
OCCUPANCY
~
lONE
REAR YARD
PUBLIC UTll. EASEMENT
USE CLASSIFICATION
FRONT j I~
SANITAR(tJ 1\
.)tDe-l,..,.
Date
SIDE EX!. REAR
PLANNING Date BLDG. INSP.
~ .3-~r-7'1
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JM~/!L -:J~~'iT-71,7
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Directions to Find Property:
COPY 1 - OFFICE
COPY 2 - JOURNAL
COPY 3 - AUDIT
Form # CSS-12
.~
CONSTRUC~N/PLACEMENT' 1-
PERMIT q 0-
FOR OFFICL USE ONLY
COMPLETE THIS BLOCK.
PLEASE USE BLACK INK AND PRINT.
~~~~t~";~~~~.
o Two C;pics of Plans
D'l'wo Copies of Plot Plans
[JMechanica1 Checklist
o Plumbing Chec}:list
. Dplan Chec); Info Sheet
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TOI_""HI" / 7_ I RANGE
~3';ZOtl
LOCZ~ ~ ~y 97 PROPOSED USl.; Or Pri.OPERn'
~l'C"'" CURRE"W~ ?RaPERTY ~ '/ '" ~ _,. ~/f1) &csidential DlndustriaI
~~~ . o Commercial DP7ic
. , iJEdf' ·
. , P ~ ~ a~ y u.,-./ ("~ A'~#~j' ./~ k,,;u7 ~a
a,sZ9: I~J!)W'I 'a~~-r\'ATERSUPP~.p~) ~~~~~~
OI<NE """IE AND A '5;%.~ ~A'W'/ a ~. \/. _?'/~. - 7;;?_Y;~7
@;;/;?A;;~.E~' ~;Y//t7 ~~ ;;R.t??/?7_ 7.?1;;fi"y
/\:6N~CTb~::;~# ~;;;. .;f-/Pf~;g~~ ~
~n~>7';~~~ // /,
r:/ ~ IS~~?/13~~OF
1 LOT/PARCE: 1 ~LOCK
I !lAVE CAREFULLY EX1l.MINED TilE COMPLETED API'LICI\TIQ PERMIT, and do h~cl'by ,-,p.ctif-i tl1ilt .111 inf..,rmiltioll h('I"')1l 1'1 trll'! ilnd 'Corre':\. ill\rl 1 fllrtll\'f
certify that any and all work performed shall be done i accordance with the Ordilla:1CCf> of I.<lne CO\lnty i.lnd th" l.aws of th,) 5Lid.<:, of Q,,,,,'JIl 1,'~:l.lihir1<1
to the work described herein. and that NO OCCUPAllCY 1 be made of any structul"~ without the permir;~ion of tlll~ Building oiviRion. I (urth"t" c-, r:;ify
thilt registration with the Builder's Board is in full force and effect as rcquir0d by ORS 701.055, that if excmpt the basis for oxemption i~ Ilot.'d
hcrcon, and that only subcontractors and employees who arc in compliance with ORS 701.055 will be us"d on this project. I HAVE RE.,O AlID CIlEC'Y..F.D TiltS
APPLICATION THOROUGHLY.
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~~
zon"~ \..."artition;
L#/di~~~~5~-
/ 0 F~PLAIN: In flood hazard area? 0 No 0 Yes, see attached sheet.
o R/{RAL ADDRESSING:
o SlUHTATION:
Y-- 9' -1.7 - '8"Z-
D.;TE
o (1I.,'ller
~n~rl.lc:;o::
o Ag<';llt
GRID COORDINAT~
Parcel SiZt',,$ ~
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D.te/~-Z7-R2-- W-
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o
Parcel i:
o PLANNING/ZONING:
Date:
N
E
Date:
S. 1. *'
B. P. #
lnstallation Record lssu~d? [] Yes [] No
Inst.allation
Specifications:
Gallon
Tank
Lineal Feet
of Drainfie1d
Maximum Depth
of Trencher.
Comments:
'\/PLANS EL!:fl.' i"" ~j omo"_-e?;
r Co,,"cnts, ~ UJ.-f .
,
/ Date:
use.Jf
o
Date'_VJ~ 0
CONSTRUCTION AUTHORIZED BY ~ PE~~IT
/~~~
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c..~' :::J' If." -../ ..,
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/f';~A?v/
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Fixed Feel Floodplain Fee S
Sq. Ft. Unit Cost Subsurface Fees S ~ -7 <r~
sL/7' ~ Building Fee S ',.:;I. ;:::::.--
Sewer/Storm Drain/Water S
Plumbing Fixtures S
Mechanical S J./ 7,5f
Plans Check Fee S rJ'~
State Surcharge S _~'7_
~ t:/
TOTAL FEE S ~ ;...;.-
TOTAL VALUATION
s
I. 4/0tJ g:p..- FEES PAID BY: .>> Check 0 Cash
~ /:" By: 7--..z7-Tf2..: /'
Date: ~":;,~.1z':/
____kJl~II'j,,, T ~V
OFFICIAL/DESIGNEE {.<:,er Ol~~ DATE
PERMIT APPROVED BY BUILDING
LANE COUNTY D8PARTMENT OF PLA."JNING & CQ1':HUNITY DEVELOPHENT / 125 EAST EIGHTH AVENUE, EUGENE, OREGON 97401
SEE REVERSE FOR INSPECTION INFORMATION
.
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SETBACKS AND OTHER CONDITIONS Of APPROVAL MUST BE STRICTLY OBSERVED, VIOLATION CAN RESULT IN REVOCATION OF THIS PERMIT,
CITATION UNDER PROVISIONS OF, LANE COUNTY'S INFRACTION ORDINANCE, AND lOR OTHER REMEDIES ALLOWED BY LAW.
WHEN READY FOR INSPECTION CALL 687-4065. 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 dlrections to si~e. . .
~
BUILDING DIVISION: "
REOUIRED lflSPECTIONS
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 mix.ing plant' (comnoj,ly termed "transit mixed") 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-f100r_bttildjng 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 subf100r. ..
. .. '. .
3) FRAMING & INSULATION INSPECTIONS: To be'made after the roof,.a11 framing, fire blocking and bracing are in place and
all pipes, fireplaces and chimneys and vents are complete and a1i roug~ e)ectrica1 and'plumbing ar, approved. All
wall insulation ~nd vapor barrier are in place.
- . -. . ~. ,
4) LATH'ANO(OR GYPSUM BOARD INSPECTION:. To be.made after all lathing and gypsum board, interior and exter,ior,~s in .place
but before any plastering !Sapplied or before gypsu"l board'joints and fasteners are taped and finished.
, "
5) 'FINAL INSPECTION: To be made after the bu'ilding is complete and'before occupan~y, ' ,
APPROVAL REQUIRED. No wo';k 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: T9 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. WOOD STOVE: To be made after completion of masonry (if apolicab1e) and when installation is comolete.
.Installation shall be in accordance with an approved'nationally recognized testlng agency and the manu-
fai;turerls i'nstallation 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.i: . .
(1) Footings and piers to comply with State foundation requirements for mobile homes or as recommended
by the manufacturer.
(2) Mobile home. minimum finish floor elevation shall be certified when required by a floodplain
management Jetter: . ,. . .' .
(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 concrete is poured. Above grade when pool
; sins ta 11 ed,~.
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 SUSPENDED OR ABANDONED FOR MORE THAN lBO OAYS. SUSPENSION OR REVOCATION MAY OCCUR IF THIS
PER~lIT WAS ISSUED ON THE BASIS OF INC0I1PLETE OR ERRONEDUS INFORMATION.
ANYONE PROCEEOING PAST:'THE POINT OF REQUIRED INSPECTIONS WILL 00 SO AT HIS OWN RISK
SUBSURFACE ANO 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 bysubmittin<g the ~ns,anation record ,form, The Deparl'!nJnt'.shall inspect. the construction to
detennine if it complie.s with the .rules contained' in this divis.ion: If the construction.doe~comply v/ith
such rules, the Department shall issue a certificate of ~atjsfactory 'completion:.to. .the permit holder, If the
construction does not comply with such rules, the Department shan notify th~' permit holder and shall require
satisfactory completion before issuing the certificate. Failure to meet the requirements for satisfactory
completion within a reasonable time constitutes a violation of ORS 454.605 to 454.745 and this rule,
. :~ ~ .,
Setbacks ~ Subsurface Sewaae Disoosal
From: Interior property 1 ines
Edge of road right-af-way
Building foundation
Wells, other water sources
Seotic Tank
10'
10'
5'
50'
Orainfield
10'
10'
10'
'100'
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LANE COUNTY TlFF-T EN'I l'1(;t RECEIPT ;:, 169782 DATE 09278:..
,','~T TIRRILL. JACK AD DR 6849 G'ST., SPRINGFIELD, OREGON
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OWNER ~M:' . ADDR
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STATE SURCHARGE
PLAN CHF:CK FEE
1400-
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EST. GnMPLETION DATE
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~NING & COMMUNITY OEVELOPMENT ...
ACTIVITY INFORMATION SHEET
COMPLETE THIS SECTION. INCOMPLETE FORMS WILL BE REJECTED!
1 ~~',11 \S~ ~rnJr'^S~'cM
-r PER50N'MAKING REQUEST
oJ ""Lie. 1/\2"'01 ,
b A <-{q I, &" 57
MAILING ADDRESS
5I;J;>11.J'1 ~"Pd c::!-112..
v crn S'IAlt
97,/0)
ZIP CODE
'7iAWiI/lc-1 LI~v--k v- e.
PROPERTY OWNER
/61 L KA-w, hL/~ ~
MAl LING AbB'RESS
)P:1Ir/5r:~fj (~ .
CITY STATE
97'-1,,--
ZIP CODE
"7 z. b - I ~ '- { 7 2. b I ~ '-I
BUSINESS TELEPHONE # HOME TELEPHONE # BUSINESS TELEPHONE #
2.. PROPERTY ADDRESS 5~.Q.. 1 biZ. RIhvI b L;~<:
(IF DIFFERENT FROM MAiLiNG ADDRESS)
F?'i6-3r:.'77
HOME TELEPHONE #
lJ-1 _
3 MAP & PARCEL NUMBER
(REQUIRED INFORMATION)
II 0 ~ "}, '~, I
~ RANGE srcTTON
(from tax maps in Department of Assessment and Taxation
or from tax statement)
"3 t..f 0 ()
fAX LOT(S) OR PARCEL #
ZONING
TOWNSHIP RANGE SECTION TAX LOT(S) OR PARCEL # ZONING
TOWNSH fP RANGE SECTION TAX LOl(S) OR PARCEL # ZONING
TOTAL CONTIGUOUS PROPERTY IN SAME OWNERSHIP: ACRES
4 SUBDIVISION (if apPliCable);)~ ~ ~ BLOCK
5 REQUEST (state exactly what you plan to do) k.o'O A-<.
t=:-I. <:..<;J''"I<, k'D D-r ,
.coM 4-;1 ,.-.J "7 V\ 111 dIU L,~
6 DIRECTIONS TO SITE:
r:r",p'~<4-7 --I,., />7DI,~-< I,..
(') t/.Javo-r.:> It/h--fA. -/-0 PmnM.14 0.
. I J
** FOR STAFF USE ONLY **
NUMBER
DATE
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ZONE/LAND USE:
BY: DATE:
TIME IN:
OUT: