HomeMy WebLinkAboutSWG93-0351 - SWG Inactive ON-SITE SEWAGE SYSTEM SITE EVALUATION AND DISPOSAL PERMIT
MASON COUNTY DEPARTMENT OF HEALTH SERVICES PERMIT NO. _ Cn D
f SITE EVA ATIO DESIGN AND INSTALLATION Q m
426 W. CEDAR/ P.O. BOXjSHELTON, WA 98584 Date I Date N
PHONE (206) 427-9670 Receipt o. X Receipt No. a
PROPERTY OWNLH: Amount$- J Amount$ Z"
�' `2�� CHECK APPLICABLE ITEMS 6/ R
MAILING ADDRESS: DAYTIME PHI E: INSTALLING NEW SYSTEM p
DO � 27 — REPAIRING OLD SYSTEM CITY: STATE:
p: EXPANDING SYSTEM �
�i✓ SINGLE FAMILY - 8
PROPER ESS: OTHER t,,v_ sL o,
�� z
— S�L SPECIFY: 3
SPECIFJ�DIRECTIONS FOR LOCATIN SITE- PRIVATE WELL C C
PUBLIC SYSTEM
SYSTEM ID NUMBER
wt/ SYSTEM NAME a +
u� — APPLICANT
Name of NAME
Installer , "� t o + ft x ls84- MAILING ADDRESS I�
Name of acres PH E 0 I�
Designer Number of ATU E
Bedrooms
PLOT PLAN I�
�a L
Draw a dimensional plot plan, to
including:
❑Precise location oft st,
holes,showing •-�/� 'c
measured distances tom-{�
property boundaries. I O
l (�
❑Entry road;other roads, L
driveways.
V Sd
5'�NIES'1 'vX
�. °6 IIs °�tQ ��. �o o
MAR35a 3
OFFICIAL USE ONLY. DO NOT WRITE BELOW DOUBLE LINE.
SOIL LOGS
b- IS�,,t' b-4 "61 over 61S 63 L(; X l) 37- CAS w HP G>^w res
�,�tbrrEs �o � q-1q U(eA Cob
0-10 � '
1-S �i 1? )q_jq*rA)4 __VMd
ft
?N#'S' O-q LS
2_'SS Aaw` Depth from Original
p 3 �����r Grade to Restrictive
YIItO} Z- �" 5 W/ "�5 Layer or Water Table: In.
DESIGNER DESIGNATION SCORES INIM "STEM REQUIREMENTS
Design:0 Level One ❑Level Two
Soil
Vertical Separation Septic Tank Daily
Slope Capacity: Gal. Flow: GPD
Appl. Infilt. Depthfrom Original
Parcel Size Rate GPD/FT2 Area FT7 Grade to Bottom of
t
Absorption area: In.
Distance to Shoreline Total Ins ec
p � Date
�� COMMENTS/CONDITIONS FOR APPROVAL
j:rn5k-0. 'e'r w i 11 C w; d �� a,>;,ems. m TR
-b owner.
5le't' A tk ca 6
�Owner/Designer/Installer must meet on site to verify precise system layout ❑Owner must arrange pre-installation conferences with health dept.staff
inter observations required ❑Extreme care needed duringsitepreparation
to preserve existing topsoil
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 issue.Denial of this permit may be appealed to the Health Officer within 10 days of denial date.
SITE:❑AMMed ❑Desig aired Not ed DESIGN: ❑Approved ❑Not Approved INSTALLATION:❑Approved ❑Not Approved
BY: DATE: '3 BY: DATE: BY: DATE:
TOP: Health Dept. Copy MIDDLE: Designer's Cnnv