HomeMy WebLinkAboutSanitary Survey - CRT Application - 11/16/1993 w 1 * MASON COUNTY
DEPARTMENT of HEALTH SERVICES
Mason County Bldg. 111 426 W.Cedar
P.O. Box 1666 Shelton,Washington 98584 . : .
(206)427-9670 • Belfair.275-4467
Seattle:464-6968 •Other: 1-800-562-5628
environmental health personal health water quality
SANITARY SURVEY
[] WATER ONLY $40. 00 [] SEWAGE ONLY $50. 00 WATER AND SEWAGE
CHECKS PAYABLE TO: MASON COUNTY TREASURER SUR# .
'EE _ RECEIPT #
SITE ADDRESS- _ .
, PPLICANT'S INFORMATION
PARCEL NUMBER-'6gy ',_� DATE
LEGAL DESCRIPTION
OWNER'S NAME���.[/ �/)�/iJ APPLICANT NAME
MAILInNG ADDRESS MAILING ADDRESS elk 7n
TELEPHONE NUMBER TELEPHONE NUMBER
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MAIL INFORMATION TO: .
STREET) (CITY) (STATE) (ZIP)
DIRECTIONS TO THE
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REQUIRED FOR,SEWAGE SURVEY '
AGE OF SYSTEM PUMPERS REPORT ATTACHE
AGE OF HOUSE YES II NO I]
LAST OWNER
HOUSE OCCUPIED YES [] NO [I
NUMBER OF BEDROOMS
REQUIRED FOR WATER SURVEY
WATER SUPPLY (CIRCLE) WELL . SPRING
WATER SYSTEM TYPE (CIRCLE) INDIV. PUBLIC
NAME OF SYSTEM
LOCATION OF WELL_
APPLICANT' S SIGNATURE DATE
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