HomeMy WebLinkAboutPermit Septic Tank 1986-9-19
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ffiount "~oGation for:
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LOT/PARCEL . BL6cK
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FOR OFFICE USE ONLY
APPl~cation,/I~~~, ~~~.
Perm~t # ~~ 5 --~~
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mWNSHIP / 7 AANGE (/ S
SJBDIVISION/PARTITION (if applicable)
PROPOSED USE OF PROPERTY
~esidential 0 Industr ial
,VD~ercial 0 Public
LOC~?~S~;?677 G~6'Y ,- .J~;;;~~~ . 9/,?/7/
,~~c:.;", CO""NT", ON">'O",'T' S . - /' ~ . ~ -' -~)
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( -;)ESC~ OF PROPOSED WORK/ BE SPECIFIC ~. (--: - DECLARED $ VALUE
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=. OF BEDROOMS ~/ # O#/~. r # OF ~ \-IATER SUPPLY ~~~, ~~~~~~~:
, O;'~AME fiND ADDRESS _ ~./ 2:: ~', .-- -, . ~ T'L,,,ON,,-.i,,,,,,,
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t>:::ffi.lIT ~ g~E MAILED ~~ 'ADDRE~S~ . L TELEPHONE NUMBE,R
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. I HAVE CAREFULLY EXAMINED THE COMPLETED APPLICATION "'OR PERMIT. 'and do hereby ce rtlfy that all information hereon is true and correct, and that I
have the following legal interest in th~ property~er of record; 0 contr,act. pllrchaser; Dautho~ized agent. .'
I f::rther certify that any and all work performed-~l'i")be done in accordance with the Ordinances of. Lane County and'the Laws of the State of Oregon
pertaining to the work described herein, and that NO OCCUPANCY will be .made of an.y st.rllcture without the perrniss~on of t:-he .Building Division. I fur-
ther certify that registration with the Builder,Is Board is in, full force and effect. ,as reC;uired by ORS 701.055,. tnat if exempt' the basis for exemption
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~ANITATION: S._ 1. # B. P. #
~ "'Installation _ J Gallon'" Lineal Feet '
Specifications: ~ 'Tank J, ' :J... f'r() of Drainfield '
r.iJ"J;;:~~. ';;,1'6 ~L ~"a,;L;f~.~
6 PLANS1 EXAMI~ ION: Type Group Use
READ THIS SECTION CAREFULLY. YOU~THORIZATION gAS BEEN BASED ON THE FOLLOWING CONDITIONS! . ~~
o PLANNING/ZONING: Zone *(Y~artitiOn # Parcel # Parcel Size-;;;;'~
. C ... / . C . , ....' .---:? ,. /"
Minimum Setbacks: ' L, front / L, s~de ./? ,:Lnter:Lor ~./ rear
Cm\lENTS://Zt ~~~/h' ~/4/'//~~~~
/..,- _/.-r /~ ?/" r -. '. Da~e: c ~~~,__
., ,;/ /' -
Installation Recor~ Issued? 0 Yes 0 No
{.'/ Maximum Depth
~ ~ ' of Trenches
~ $ -;;fLu dtL.td~
.(j'1-17-f{ ~
Date:
COMHENTS:
Date:
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? PERMIT APPROVE
_ !?~s: cry! /C
ING'OFFICIAL/DESIGNEE (per ORS 456.805(1)) DATE
PARTMENT OF PUBLIC WORKS LAND MANAGEMENT DIVISION, 687.4061,
125 EAST 8TH AVENUE, EUGENE, OREGON 97401
SEE REVERSE FOR INSPECTION INFORMATION
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ACTIVITY INFORMA l"IO!~~H EE~r
-
..1...... .
COMPLETE THIS SECTION. INCOMPLETE FORMS WILL BE REJECTED!
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.,,,..,, '., " .
r~J1x \ ~Elfl~R~~rREQUEST .
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~ . MAILING ADDRESS
j S P I'Uh\A ~~~ (~rL q 1 <f-17
1 . CUV STATE ZIP CO Dr
1}(O '1/1,5'3 ' 7lf1 ,8 P0 <6
1 BUSINESS TELEPHONE # HOME TELEPHONE #
I I ~A
~ 2 PROPERTY ADDRESS _ '/fil (Yl/b
. (IF DIFFERENT FROM MAILING ADDRESS)
?)A!ltb
PROPERTY OWNER
6AME
MAILING ADDRESS
gA-wJ3
CITY
STATE
ZIP CODE
~rJ...Q-
BUSINESS TELEPHONE #
.5IJi'VLG
HOME TELEPHONE #
,
! 3 MAP &. PARCEL. NUMBER.
(REQUIRED INFORMATION). .
(from tax maps in Department of Assessment and Taxation'
or from tax statement)
/703 "3<(,).). '.~ . 00600
TOWNSHIP RANGE SECTION TAX LOT{S) OR PARCEL # ZONING
TOWNSHIp. RANGE SECTION
TAX LOT(S) OR PARCEL # ZONING
TOWNSHIP RANGE SECTION
TOTAL CONTIGUOUS PROPERTY IN SAME OWNERSHIP:
TAX LOT(S) OR PARCEL # ZONING
i~
/ L- ACRES
i 4 SUBDIVISION (if applicable)
5 REQUEST (st"ate exactly what you plan to do) ~jJ,f9~~'
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LOT BLOCK
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,. (l 1.lot I ({,\
f,tJ f 1\ \...UV\I\. 'i()' i 0,-,,-1 "
6 DIRE cn ONS TO SITE: 'F;;, rJY\. (rv.,jJ)JI/'rV,-Al
4th at ~'r'e<<
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** FOR STAFF USE ONLY **
ZONE/LAND USE:
14-33
~
LAND MANAGEMENT DIVISION / 125 E. 8th AVE., EUGENE, OR 97401 / 687-40'61
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PI 01:
Subdivision
Lot
. C74-150
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