HomeMy WebLinkAboutPermit Septic Tank 1983-10-20
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VICINITY MAP,
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. ;n~taller '13K'fJU It DO ,~s+. ,~c
('htle as shown on DEO lice'}S~
Telephone , f7 'I~'5!-J:57
,cense No. .!},:;) d-K-?
BondY.J9 .C.?~pa2,v ~r,.,"" S .
. fd-dP ~ Date r---6~~
ISigflature of Licensee) tl
If Installed By Owner-
Date
(Signature of Owner)
Applicant's Name & Address
:So HAl' 0' t V e tJ
, '?~ r:, / '73erldl./ 1/, ew
50 ffJ "t 97'/'77
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form c55-11
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. v:1 ' MUST BE IN BLACK INK ..
Permit No. j5"'f(J -0' Twnshp, 17 Range 0 3 ,Section ;1. 3 Tax Lot
Standard System 0 Alternative System 'Q! (Speci~ ~Y.lljle~ " ;< P,~ Pil~<
Job Location (Street Address) WlO....U\ \} ,QM) {....-M.. .
Subdivision / Partition # . Parcel, L t Block,
DETAIL SYSTEM PLOT PLAN' AS CONSTRUCTED
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USE BLACK INK ONLY Gr'avel Depth Below TI'I~, . /" r"
FOR INSTALLER'S USE: Trench Depth .30 ~'.' ~ CD
Tank Capacity, 1"'/J1tr..'1()Wl1. Manufacturer, l-< rJ K/\ 61 w/l
Measured Distance from Well to Tank JI 'f . From Drainfield I Z-z....
. 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,)
Total Length of Lines.j 2L(
(Model No,) .Pump
h'!ve been installed with this sewage installation,
Signaturp
, Datp
FOR SANITARIAN'S.USE ONLY: f "h System f~pprQved 0 System DisaRproved 0 Needs Correction
COMMENTS: The lssuance 0 t s Certl lCate is based on the i,nstaller's statement
. noted above. . -
, ("I, C / A-1 System it>rrect~.d? Date C (
System 'Capacity _~O gal./day Signaturp. '>()~..n./7 Date ICJ/:z.eJ/83
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INSTALLATION'.'RECORD & CERTIFICATE OF SATISFACTORY COMPLETION When signed by the County Sanitarian, this certificate is
evidence as p~r ORS 454,665 ~of satisfactory completion of a subsurface sewage disposal system at the above location,
Return tnis form to: Building and Sanitation Div" Dept, of Environmental Management, located in the basement of the
Public Service Building. 125 E. 8th Avenue, Eugene 97401, '
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