HomeMy WebLinkAboutPermit Plumbing 1996-11-12
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2-::>82 0'/_ MUpI..,BE IN BLACK J.N.K form c55-11
Permit No, ~ c.- -l IV Twnshp. -.LJ Range ()_ S Section 2-7.3.3 Tax Lot / ~ l/6J
Standard System 0 Alternative System '5((S8e;:ify Typy) , .P'Il(~5CJt;:./ Zeo
Job Location (Street Address) I Lf ---:2-7 '1/'7 ~~~ L A./ ) 5tP~
Supdivision/Partition # ' ~ , Parcel Lot _ Block'
DETAIL SYSTEM PLOT PLAN AS CONSTRUCTED
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USE BL~CK INK ONLY
FOR INSTALLER'S USE: Trench Depth f).. Gravel Depth Below Tile
Tank Capacity /()()I'J Gal Manufacturer Cut t \ . c...l"'C<.y 5f-DAe
Measured Distance from Well to Tank -'-f2l- \ From Drainfield 1 I!J / Total Length of Lines fL~S-
COMPLETE THE FQLLOWlNG If A PUMP WAS USED ON THIS INSTALLATION: ....-?'I
I (installer's name) lit.. -\..0 .J{l,,~-tc"r'" certify )J1aL~ (Mfg.) I./. P (")rrA-G.l> (Model No,) t< P I~ l.I Pump
and Mercury Float Switch (Mfg. and No.) i<f 15V have been installed with this sewage installation.
Signature L->o--..cc,\u-S ~~~ Date /6 - /0 - Y f-
FOR SANITARIAN'S USE ONLY: )g:.. System Approved 0 System Disapproved 0 Needs Correction
COMMENTS: ~~ss...-..t.. ~ .~ 'L~t-I..:;Iq~ _m ___ ___
<? ,\
~ &tSij3m.~ted Date
System Capacity 4stJ gal./day Signatur~~A~1f~- Date //,/12!,!;_
INSTAllATION RECORD & CERTIFICATE OF SATISFACTORY COMPLETION When Signed by the County Sanitarian this certificate IS eVI-
dence as per ORS 454,665 of satisfactory completion of a subsurface sewage disposal system at the above location,
To request inspection, return all three (3) copies of this form to: lane County Environmental Health Services, located in the basement of the
Public Service Building, 125 E, 8th Avenue, Eugene, OR 97401,