HomeMy WebLinkAboutCRT92-0102 - CRT Application - 9/1/1992 r
MASON COUNTY
DEPARTMENT of HEAL* SERVICES
Mason County Bldg.III 426 W.Cedar
P.O.Box 186 Shelton,Washington 98584 t
=)427-9670 a Beifair:275.4467
Seattle:464-6968•Other. 14ED-562-5628
environmental health personal health water quafity
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,report obtained and su itted with
fadiities application;then call for inspection.
2) Community water system. 2) If no system on record
If on an approved community system,no inspection or Tank pumped,report obtained,submitte I with application,
sample is necessary. portion of drainfield lines exposed to ver fy size and
existence of drainfield.
WATER&SEWAGE S68.00
This is 0 both water&sewage are done at once.
Checks Payable to:Mason County Treasurer
APPLICATION FOR REPORT ON INDIVIDUAL SEWAGE DISPOSAL SYSTEM AND/OR R SUPPLY
It is the established practice of many lending institutions to obtain information from the local health department pertalnir g to the acceptability
of the individual sewage disposal system and/or water supplies.
INFORMATION REQUESTED ON: B INDIVIDUAL SEWAGE SYSTEM ❑WATER SUPPLY
Located at: r fir e f n Q C, 'c'
wmw su.w ,i CP. �
Directions to Property
Assessors Legal Description: r i 0 L<b Lon—
Assessors Twelve Digit Parce(Number:3— I ;3—q— Q Q
Owner or Bulkier.
:. Year Home Built:
� c� '' ` +� � "
h
Purchaser: �; c � ' 'j. � � k� Number of Bedrooms: i
Send Report to:
n ,:..2. Name " ,.-, �
50i
a
Signature of Applicant: ' �'" '" ' Phone: r
FOR HFAILTHIDEPARTMENTti1BE ONLY
DATE FEE -J ) RECEIPT#
SEWAGE DISPOSAL SYSTEM Date—Site Inspection &—Z ' 5
House Oocu fed O House Vacant Date—Final Inspection ^ O- 6
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.
Files have been searched and no records have been found.An on-site inspection revealed no
apparent system malfunction.Only accessible yard area surrounding the home was inspected.
Other:
WATER SUPPLY:
The supply does conform with drinking standards of this department.
Remarks:
Signature Date