HomeMy WebLinkAboutCRT92-0138 - CRT Application - 10/28/1992 MASON COUNTY
DEPARTMENT of GENERAL SERVICES
Courthouse Bldg. 3, 426 W. Cedar
P.O. Box 186, Shelton, Washington 98584
(206)427-9670
building environmental health maintenance parks&recreation planning sewer&watq,C
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WATER SUPPLY$40.00 SEWAGE SYSTEM $50.00
1) Private Wells 1) If system on record
Water Sample taken by health official; inspection of Tank pumped; receipt obtained a submitted with
facilities application, then call for inspection
2) Community water system 2) If no system on record
If on an approved community system, no inspection Tank pumped, receipt obtained, submitted with
or sample is necessary. However, approval is application, portion of drainfield lines exposed to
subject to adequate sample history verify size and existence of drainf eld
Checks Payable to:
WATER & SEWAGE $68.00 Mason County Treasurer �/ _
APPLICATION FOR REPORT ON INDIVIDUAL SEWAGE DISPOSAL SYSTEM AND/OR R S&
It is the established practice of many lending institutions to obtain information from the local health dep ent
pertaining to the acceptability of the individual sewage disposal systems and/or water supplies.
INFORMATION REQUESTED ON: XINDIVIDUAL SEWAGE SYSTEM ❑ WATER SUPPLY
Located at: 1401 o�✓ L R K 120�D /f C i oiu 8 ��
Number Street City Zip
Directions to Property: -7rll c H E
Legal Description: L
3a I -s - o
Owner or Builder: A,/I L • M/TC H F C L Year Home Built: � f -
Purchaser: w,4 Number of Bedrooms:
Send Report to: L� r� /-" fti F��� .� L^r/� aM
Name
0 Z6 39 '9 gS
Address _ City Zip
Signature of Applicant: Phone: Z 6 - -S 5
FOR HEALTH DVAjRTMENT USE ONLY
DATE: �Q�o�d / 7oL FEE Q � RECEIPT # iL
SEWAGE DISPOSAL SYSTEM Date—Site Inspection V" 3a
House Occupied ❑ House Vacant Date— Final Inspection
,VX
10-321-TZ- It is the opinion of this health department that this individual sewage system is functioning
satisfactorily at the time of inspection.
Sewage was discharging on the surface of the ground.
There are indications that this system may malfunction at times.
There is indication of malfunction on nearby properties.
Other:
WATE SUPPLY:
The supply does c m w h drinking standards of this department.
R
i Remarks:
Date a