HomeMy WebLinkAboutSWG Application - 5/27/1965 el
4TU;Ri ON-MASON HEALTH DISTRICT
• DIVISION OF SANITATION
Court House Annex Court House Annex
Shelton, Washington n Olympia, Washington
Phone 426-8515 , [ (U g� f 600 cf Phone 352-4851
APPLICATION TO CONSTRUCT OR ALTER AN INDIVIDUAL SEWAGE DISPOSAL SYSTEM
(Application Required for Each Installation)
Property Owner '�, �k^fir ,A,4f?9-Telephone
_ (Please Print) - -----
Mailing Address (9J'd L='e'✓ _
Address of Site _C�I'�vEy.'�-t�►� vt y ;' 7r
Location of Property, including: Lot # Block # Other
Detailed directions to site:
Property Commercial
Size Residence No. Bedrooms _ Basement Type
Water Supply: Public Well Spring Other
Is any water supply or body of water within 50 feet of sewage system? Yes No
Septic Tank `?3 C1 gallons. Drainage System Length %5et feet. Trench Width
feet.
(Refer to Table 1 of Bulletin)• (Refer to Table 2 of Bulletin)-
And/or system other than above
Check for Installation of:
Automatic Laundry ( ) Automatic Dishwasher ( ) Garbage Grinder ( )
Is Contractor installing septic tank? Yes No No Drainfield?? Yes -X. No
Name of Sewage Contractor .1 47 a Yam, I vyj J ✓ 1/-
SEWAGE CONTRACTOR MUST BE LICENSED BY HURS7ON-MASO14 HEALTH DISTRICT
SKETCH PLOT PLAN AND PLANS OF PROPOSED SYSTEM ON SEPARATE SHEET OF PAPER
THE UNDERSIGNED hereby applies for a permit to construct a new ( ) and/or alter ( ) a sewage system
on above property in accordance with he Bulletin.*
Applicant's Signature
Address ���
*Bulletin: Washington State Department of Health Bulletin - . S. No. 1 entitled 'A Septic Tank System for Your
Home",for minimum requirements.
(NOT TO BE FILLED IN BY APPLICANT)
6�
III
Permit I�. `t\/-�--- Fee��-------- Date Issued /(q_ -------------------------- By -- - -
A-----------------------------------
Area ------------------------------------------------------------------------------- Sanitarian
---------------------------------
Dates Inspected ------------------------------------------------ Remarks -
------- -- -------------------------- _--
Date Approved •------------` ----------- --- -- - Approved b------ ---- - -------- ------ ------------
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