HomeMy WebLinkAboutSWG94-01261 - SWG Application - 9/22/1994ON-SITE SEWAGE SYSTEM SITE EVALUATION AND DISPOSAL PERMIT
PERMIT NO. SWG C.! —
MASON COUNTY DEPARTMENT OF HEALTH SERVICF-S
426 W. CEDAR / P.O. BOX 1666 / SHELTON, WA 98584
PHONE (206) 427-9670
I-'RO r 1 NE
MAI k -V-1 S:
CITY:
PrO RE$jq
DAlE:
Date
Receipt No. (////__..3
Amount $ 1 -) 5 r .%T\
CHECK APPLICABLE ITEMS
INSTALLING NEW SYSTEM
REPAIRING OLD SYSTEM
EXPANDING SYSTEM
SINGLE FAMILY
OTHER
SPECIFY:
PRIVATE WELL
kAt'TIME PHONE:
liV�
S ATE 4770(
?t r� TC -1 Loy
SPECIFIC DIRECTIONS Fg19 LOCA-rIN T
4> PUBLIC SYSTEM
✓ SYSTEM ID NUMBER,
b " `t A...1. 1A-) 409-k/ U SYSTEM NAME
� �.y� � APPL A_ N
�b�t'1Ll RC2t ) %iT " Lt+� NAME) 1 �:
6 RESS
A.
Name of Lot�ft. x0 ft. Mil
Installer
Size:
Number of
Bedrooms
Name of
Designer
PL
Dr
inc
❑ Ise loc
sh
N
nsional pllan,
LLJ
tion of Cs)
tanc
oundari
La„ 2
net : L%8 NOT 1 'fW IN
SYSTE M+' SIGN _(�j`--
acres
14
OFFICIAL USE ONLY. DO NOT r/III E BELOW DOUBLE LINE.
/ d am. roc._
DESIGNER DESIGNATION SCORES
1 Finding 1 Score
1�
C.)% 0
/,J-6 Ac. 1,
Soil Type
Vertical Separation
Slope
Parcel Size
Distance to Shoreline c.i ft.
0 I Total I l
SOIL LOGS
Designer Level:
45 -6 -7f -
0
3T
0 _/3 u.t.
13 I 54-“ ce 4 6'� A -"'s.
(-11- I)
z
v
Depth from Original
Grade to Restrictive
Layer or Water Table: 1 In.
MINIMUM SYSTEM REQUIREMENTS
❑ One
Septic Tank
Capacity: / G c2Gal.
Appi.
Rate ' (=:. GPD/FT2
Inspector
COMMENTS/CONDITIONS FOR APPROVAL
cwo
Daily
Flow:
GPD
Infilt.
Area FT2
Date�> d�
Any change from the specified use of the property or any site alteration affecting the system design may invalidate this permit.
This Permit expires 3 years from date of site inspection. Dental of this permit may be appealed to the Health Officer within 10 days of denial date.
SITE: ❑ Approved 1irDesign Required ❑ Not Approved DESIGN:
BY: �� D) DATE: BY:
•
❑ Approved
❑ Not Approved
DATE:
IINSTALLATION:❑ Approved ❑ Not Approved
BY: DATE:
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