HomeMy WebLinkAboutCRT92-0172 - CRT Application - 12/8/1992 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 plann�g sewer&water
a
WATER SUPPLY $24 W ANW1 y o • O D SEWAGO SYSTEM $49M
1) Private Wells 1) If system on record
Water Sample taken by health official; inspection of Tank pumped; receipt obtained and 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 drainfi Id
Checks Payable to:
WATER & SEWAGE $fSXi00 58;0(` Mason County Treasurer
APPLICATION FOR REPORT ON IN IVIDUAL SEWAGE DISPOSAL SYSTEM AND/OR WATER SUPPLY
It is the established practice of many lending institutions to obtain information from the local health department
pertaining to the acceptability of the ind ual sewage disposal systems and/or water supplies.
INFORMATION REQUESTED ON: INDIVIDUAL SEWAGE SYS EM ❑ WATER SUPPLY
Located at: E d Ea3e. _:5 4 G
Number street City Zip
Directions to Property: C E O S L/. !�
- /25 T / No a �N ,s/oE �'o « x�
Legal Description: X S _
Owner or Builder: /E 1ZI l/Eeie Year Home Built:
Purchaser. /��E� /��D%�(,/1�f� Numberof Bedrooms:
Send Report to: L S
Name
Address __; City Zip
Signature of Applicant: Phone:
FOR HEALTH DEPARTMENT USE ONLY
DATE:J( �C�a FEE RECEIPT #
SEWAGE DISPOSAL SYSTEM Date—Site Inspection �2—10
House Occupied KI House Vacant Date— Final Inspectio
1240'g2' It is the opinion of this health department that this individual sewage system Is fL nctioning
satisfactorily at the time of inspection.
Sewage was discharging on the surface of the ground.
There are indications that this system may malfunction ,gfotimes.
There is indication of malfunction on nearby properties.
Other.
WAT R SUPPLY:
The supply7 tonf drinking standards of this department.
i Remarks:
Date C7 — q