HomeMy WebLinkAboutPermit Septic Tank 1983-8-9
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Installer 'Er/Jul1 'Do ~sJ, ~C
(Title as shown on DEO license)
Telephone _11 LIt. , 'r.C:;-S ~
License No. ~28'q-
BOn~gJ:om~an rfZa.. Y' M,t?-r.!J ~S
J~ DatA ~-?f-83
(Signature of Licensee..t t1
If Installed By Owner-
Date
(Signature of Owner)
Applicant's Name & Address
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MUST BE IN BLACK INK
Permit No. ~ 3,5"-E3 Twnshp. .i.:!l Range 0 ~ Section
Standard System 0 Alternative System 0 (Specify Type)')
Job Location (Street Address) l..{.A:)/~
Subdivision / Partition # Parcel
form c55-11
Tax Lot ~ 'f - / ~O(/
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, Lot
Block
DETAIL SYSTEM PLOT PLAN AS CONSTRUCTED
Scale ~ ;)0 '
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ly inspected the system shown hereon and certify that it is
1.Jj,.!t"I\ll~ compliance with yhe provisions of OAR Division 71"
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USE BLACK INK ONLY
FOR INSTALLER'S USE: Trench Depth :z. L.l1/ Gravel Depth Below TilE"
Tank Capacity /tJOO Manufacturer IE(.,(C~ S /rNP
Measured Distance from Well to Tank C.i+lj HJ,.P From Drainfielrl
COMPLETE THE FOLLOWING IF A PUMP WAS USED ON THIS INSTALLATION:
I (installer's name) certify that a (Mfg)
and Mercury Float Switch (Mfg, and No,)
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Total Length of Lines 3c(j;'
(Model No.) Pump
have been installed with this sewage installation,
SignaturA
Date
FOR SAN ITARIAN'&,IJSE; ON ~f'5jyste. m. Ap~roved n 0 S)(stem 1j)isapproved ,Q1:!e.GJls Correction
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o System Corrected ,DatA.
System Capacity -1tStl gal./uay 0,,;nature ~ .C--c:u, DatE" H"~,-Yl
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INSTALLATION RECORD & CERTIFICATE OF SATISFACTORY COMPLETION '-VVhen signed by the County Sanitarian. this certificate is
evidence as per ORS 454,665 'of satisfactory completion of a subsurface sewage disposal system at the above location,
, -~-''''--~.''':~_f'''r.r.r.\_tc,,-Water Pollution Control Div, Dent, of Fnivronmenti'll Manaaement. located in the basement of the