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STAT; Eli' MOO OcrAlirri eNT or 71;NyIROW IP NTAL Qv/ dart CERTIFICATE OF 3ATISFACTCRY COMPLETION SUBSURFAOE OR ALTERNATIVE SEWAGE 8$STEM
Name of owner_//.. l
assailer'. nnma_,__ - — Sellage-Ceaayml Ilcerne No
Business addreect4
7
Exact . ..
i 1:
of proposed sewage disponi systee _ %
r- %w,_-
L
Total number: Living Unita
3
L
godroomtt.
Baths._
Watersupply: Publicsystem 0 Community sTstemjp
Weep 411110 Cistern O
Septictank: Material
Tota( liquidapaeltylb
ettei
g,•
Distance from: Well. springs, or cistern
ft. Enitding foundation i© _
SubaarfacetieorperforatedpipedisposalCe!d. X
Ot1. er
Distribution bac: Yes r No, Length each line: /
IS /% fit IL
Total length: . . . . . .
2)
ft
Widib of trench: . . . . . . __
2_ ft.
Total squire footage:
y<O It.
Distance between lues:... Filler material: Typ- /
O ft.
j. _ /
2—
Si:, o '
in Distance of subsu•( aee or other type of system from: Water !inn_ _:, Cistern___ Jt_ WoIL_ __--_ fl.. Nearest River ft. Neareet lot line: Front _ __ _ . _ Side Nearest foundation ft Sprtnp ft. Stream_ ___ ft. Lake.. ft_ tear _ _ ft
In :. r. , rdanre with Oregon R'' vised Statute Q,", , ECJ this eor'ifirate h :, snort , c virir r;;t o"-. atkfictory completion of c subsurface or alternative sewage disposal system et the • ' tovo location. C: te of prei. minary site approval late " f f e, n p^ rt: on NOT approved Sofl rondlti. trs obasrvcd Apyravc l " 7"::
pi t';. }.. t; r Ilrn ' r
Y.yr;. lw c+71 FaaeaN. r
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