HomeMy WebLinkAboutSWG2004-00594 - SWG Application - 10/29/2004ON-SITE SEWAGE SYSTEM PERMIT
MASON 1 COUNTY DEPARTMENT OF HEALTH SERVICES PERMIT NO. SWG — [}(j
\40.46 W. CEDAR / P.O. BOX 1666 / SHELTON, WA 98584
PHONE (360) 427-9670
PROPEFOWNER:•L\
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CITY: STATE:
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PROPERTY ADDRES
SPECIFIC DIRECTIONS FO OCATING SIT .
Name of
Installer
Name ofi,
Designer
Lot
Size:
DATE:
Date
Receipt No.
,Amount $
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Number of
Bedrooms
34 : ft. X 3�
acres
ft.
CHECK APPLICABLE ITEMS
NEW SYSTEM
REPAIR SYSTEM
TABLE 6 REPAIR
MAINTENANCE REVIEW
SINGLE FAMILY
OTHER:
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COMMUNITY WELL/PUBLIC SYSTEM
SYSTEM WFI #
SYSTEM NAME
APP1. DANT
.NAME
MAILING ADDRESS 0,`1
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OFFICIAL USE ONLY BELOW THIS LINE
DEPARTMENTAL SOIL LOGS
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SOIL TEXTURE CODES:
V = Very G = gravelly S = sand L = loam Si = silt C = clay E = Extremely
DEPARTMENTAL COMMENTS/CONDITIONS
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PECTOR (print ame)INTION SIG� RE DATEjPERMIT EXPIRATION DATE
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•All systerd require ongoing Operation and Maintenance (O&M) as spcified in Mason County On Site Standards.
• At on-site sewage systems must be designed by a Mason County Certified Designer or a Professional Engineer, unless prior approval is granted otherwise
• All on-site sewage systems must be installed by a Mason County Certified Installer, unless prior approval is granted otherwise. In such cases a preliminary on-site
meeting between health department staff and the homeowner is required.
• On-site sewage system design approval does not imply other building site requirements (i.e. RLC, Water Adequacy) have been met.
• Any change from the specified use of the property or any site alteration affecting the system design may invalidate this permit.
• This of fin}expires 3 years from the date of site review. Denial of this permit may be appealed to the Health Officer within 10 days of denial date.
DES }f 'N VIEW APPV'AL DATE: IN ALLATI.N APP Y: DATE:
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TOP: Health Dept. Copy MIDDLE: Designer's Copy BOTTOM: Applicant's Copy