HomeMy WebLinkAboutPermit Plumbing 1983-1-27
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VICINITY MAP
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Installert""'~ ex<9A-V14'r1~ {Pc,
(Title as shown on OEO license)
Telephone _ c:.eq -0'1 SI
:ense No, 4-.::> ~ ~
":::;;'d;ng Company ()" rrE'Y'> P"",-,'Ft"'--
ISigna~r~ of {;(.n~ '- - Date (JZ;M'3
If Installed By Owner-
_ Date
lSignature of Ownerl
Applicant's Name & Address.
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form c55-11
T ax Lot ..J de
. MUST BE IN BLACK INK
Permit No, -2$"-$.3> Twnshp. 17 _ Range (l'\ ~ . Section L ~
Standard System~Alternative System [J (SpecifW.!e)......./- - _', __
Job Location (Street Address) ?4 ..2..7 . ~/ ()I'1e.J-V I-n... )'- G ~p
Subdivision 1 Partition # Parcel :(ot c::../ Block.
DETAIL SYSTEM PLOT PLAN AS CONSTRUCTED
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USE BLACK INK ONLY
FOR INSTALLER'S USE: Trench Depth '2...4- .... Gravel Depth Below TilA
Tank Capacity. 1.060 Ch M.... Manufacturer~CJ~~ c:;: ~ .i ~ ~
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Measured Distance from Well to Tank From Drainfield Total Length of Lines_' S-C '
COMPLETE THE FOLLOWING IF A PUMP WAS USED ON THIS INSTALLATION:
I (installer's name) certify that a (Mfgl
and Mercury Float Switch (Mfg. and No.)
(,... l..<
(Model No.1 .Pump
have been installed with this sewage ihstallation.
S ignaturp
. Date
FOR SANITARIAN~SE OoNLY: ~System;oApprq~d( 0 SysternJ?isapprov,ed ~ 0 ~;;;;ection
COMMENTS: ulhe (~Vcyl"'LCJ!, (rl-'. ~h/~~?t:I+7"'-..-/", "'Ce'~ .
~ n ~ ,nsrn .//er'.s sC.c::....Ueh7C::b~,; .
. r--) t'J ~ystemLPOrffict~d /J Date ~) ,
System Capacity ~n gal.! day Signatur~~L!lr./~~~~ Date-Lf~ -VJ?-~
INSTAl:tATION RECORD & CERTIFICATE OF SATlSFAcf6~y COMPLETION When signed by the County Sanitarian, this certificate is
evidence as per OR S 454.665 of satisfactory completion of a subsurface sewage disposal system at the above location.
I'RETURN TH IS rvnl\4 Tal 1 DEPARTMENT OF PLANN I NG AND COMMlHTTY DEVELOPMENT
! COt..IR'niOlJSE:! PUSL I C SERV I cE au I LOI NG I 25 E. 8 TH AVE. EUGENE. OREGON. 9 740 1\