HomeMy WebLinkAboutSWG Application / As-Built - 6/21/1978 ' 5th 6 Birch, P.O. Box '746 'THURSTON-MASON HEALTH DISTRICT No.
Shelton, Wash. 98584 oIVI/ION Or ENVIRONMENTAL HEALTH Courthouse nex
Phone: 426-4407 Olympia, ash. 98501
T�GTG el Phone: 3 2-4851 EXT 84T
OWNER W l V I /�u)l�''" T PHONE
OWNER'S ADDRESS / / Y CITY / QTATE c LA
SEND REPORT TO /� �/�� CITY TATE
SEWAGE CONTRACTOR 31,rriyLlj' /l9z ADDRESS '
(If self,
confer with E.H.S.) p � �
LEGAL DESCRIPTION 4- J
PARCEL NO. LOT SIZE 70 C1 X 9 o INTENDED USE OF av
NO. OF BEDROOMS NO. OF BATHROOMS BASEMENT PLUMBING: YES NO
NAME OF WATER SYSTEM �2—' INDIVIDUAL PUBLIC COMMUNITY
—
DIRECTIONS l � `
DIRECTIONS TO PROPERTY: (Be Specific)
DRAW A SKETCH SHOWING: 1. Property lines, location of hrivae on the lot, and dimens ons of the
lot. 2. Location of the house and sewage disposal system in relation to streams, likes, wells,
soil log holes, patio, driveways, underground tanks, water supply lines and easements.
The septic system is an .approved temporary method of sewage
disposal until aazti tars sewers are available. _
D0. NOT WRITE IN THIS SPACE
MINIMUMS: �7
Septic Tank •1,
Drainfield -I
SITE APPLICATION
APPLICANT'S SIGNATURE DATA ( /-
SITE INSPEqTION FEE _RECEIPT NO._, _t BY ,
APPROVED? POT APPROVED BY
D e Date Inspector/E.H
l—T SEWAGE APPLICATION NEW /—T ERATION
APPLICANT'S SIGNATURE DATE
FEE RECEIPT N0. BY
PERMIT NO. b.S� APPROVED d BY `
at Inspector/E.H
1
1
THURSTON-MASON HEALTH DISTRICT
DIVISION OF SANITATION Rec E ipt # �
5th & Birch Cour house Annex
Shelton, Washington _ �// Oly pia, Washington
Phone: 426-4407 SITE INSPECTION # 1 J �1 � Phon : 352-4851, ext 84
APPLICATION TO CONSTRUCT OR ALTER AN INDIVIDUAL SEWAGE DISPOSAL SYSTEM
(Application required for each installation and/or major repai )
Buyer or
Property Owner 1k�a�� Phone
Mailing Address ity State Wa-4 Zip q �fJ��
Builder � ,ti� Address Zip
Location of Property, including: Lot# - ±0 Block#_ Other: p�
r'cca�-so to l�Mailing Address of Site: A 6C �-Oq.aL (�o
(With directions to ite)
Propert " � �''� Commercial
S Size D �C �D Residence1�� rt{n- p�w�t� of Bedroofms—�—�Basem ent Type
Water Supply: Depth of Well Spring Other
Is well or body of fresh water within 100 feet of sewage system? `(`p
Is salt water supply within 50 feet of sewage system?
Septic Tank � gals. Drainfield Length ft. Trench width ft.
And/or system other than above
Is garbage grinder being installed? Is contractor installing septic tank?
(Sewage Contractor must be licensed by Thurston-Mason Health District)
THE UNDERSIGNED hereby applies for a permit to construct ( ), alter ( ) Ind/or modify ( )
a sewage system on above property in accordance with minimum requireme is and standards
of the Thurston-Mason District Board of Health.
APPLICANT'S SIGNATURE
�'Zl��� TO.BE FILLED IN BY APPLICANT
Permit # z4�9Ao2, Fee d Date Issued_?/3_%p B
Area Sanitarian Date Inspected
REMARKS:
Date Approved: &4f— -7� Approved by
TI`IH-S-5 9/69
SEW, CONTR. Sa itarian
3a ado - sv oao�8 0 Q�l
No n
THURST%6MASON DISTRICT HEALTH DEPARTMENT
Court House Annex Division of SanitatiAn Court House Annex
Shelton, Washington Olympia, Washington
Telephone Ha. 6-8515 Telephone F1, 2+4851
APPLICATION TO CONSTRUCT OR ALTER AN INDIVIDUAL SEWAGE DISPOSAL 'YSTEM
!� (Application Required for Each Installation)
Property Owner d 0 TIiEA�V Al
Telephone
Please Print)
Mailing Address SAArnYS Rr d'o T
Address '�? wY✓O (1s IFeJ0A17- T p•v 11j of Site Ta )4 v Y A
Location of Property, Includingt Lot N Block N Other'CiVec BeAjW�pX�� ( �
(detailed directions to site)
Prope Y Commercial
Size 0 k y G O Residence No,Bedrooms Basement Type l/
® Water Supply: .Public ,Well ,Spring Other
water Is any water supply or body of ter within�eet of sewage system? Yes No
SKETCH PLANS AS DESIGNATED ON BACK SIDE OP THIS SHEET
Septic Tank 7Mgallonso Drainage System Length J S-feet. Trench Width inches.
and/or other F,H,At Yes No
:Y.eck for Installation of:
Automatic laundry (kO), Automatic dishwasher 0N111, Garbage grinde (AF,
Is Contractor installing septic tank? Yes_�_Nq ; Drainfield? Yes X 1No
:lame and address of
S^-wage Contractors__ ���✓ 1 .c w�
T:-LE UNDERSIGNED hereby applies for a permit to construct a new ( ) and/or alter(
a sewage system on above property. The construction and specifications are is be
in accordance with the "Minimum Requirements and Standards Regulating Sanitary
Sewage Disposal in Thurston-Mason Counties
Applicantts
Signature ) Addresst
e
x NUMt Please refer to "Minimum Requirements and Standards Regulating Saritary
Sewage Disposal" and the accompanying drawings,
(Not to be filled in by applicant)
Permit No,M1 Fee $7,50 Date Issued By
Area
Sanitarian
Dates Inspected-a----,Remarks
I
Date Approved he C7
12/59 (OVER) Sanitarian
SKETCH AND DESIGNATE THE-FOLLOWING: . ; .
I.•-:Property lines and names of streets.
2. Locate all buildings, driveways septic tank and/or orther, drainfie d,
'distribution,box and trees,., -
o
3. Dimensions of septic tank and drainfield.
4. . Location of and distance"tb:`any stream; Take;'Puget"'Sound, 'or-other
bodies of water within 1= feet ,of sewage system.
5. Location and type of wells or other-water 'supplies within"100""feet- '"
of sewage system. .
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