HomeMy WebLinkAboutSWG92-0607 - SWG Application - 8/28/1992 MASON COUNTY DEPARTMENT OF HEALTH SE VICES PERMIT NO. - y
/ SITE EVALUATION DESIGN AND INSTA LATION a m
C Date Date ≤. C.,
426W. CEDAR/P.O. BOX' SHELTON, WA 98584 Receipt No. Receipt No. a y
PHONE (206) 427-9670 Amount$ 4-C Amount$ z
PROPERTY OWNER: DATE:
CHECK APPLICABLE ITE IS �/ 3
z7- 9zm
MAILING ADDRESS: DAYTIME PHONE: INSTALLING NEW SYSTEM C
D Sept 75Y REPAIRING OLD SYSTEM
CITY: STATE: ZIP: EXPANDING SYSTEM U)
E S7 OLYnPi9. wA 92:4 p SINGLE FAMILY
PROPERTY ADDRESS: OTHER z
SPECIFY: J LeA3
SPECIFIC DIRECTIONS FOR LOCATING SITE: PRIVATE WELL ._t;, Cr
70 0 L/ ;)Ay flS.4CM . /7D r/7 jy, J r PUBLIC SYSTEM
SYSTEM ID NUMBER
ThoUc flocr. XF7 ON ✓ANDY 4V6 SYSTEM NAME
APPLICANT \ _
St O"St ON /Z NAME L••.•r IryA
Name of Lot 5 C� ft.xft. AILING ADDRESS o (�
Installer -y ti c
Size: acres
$► ) TELEPHONE )#9 - 1p Nam0 _
e of
ner Number o SIGNATURE / o
Designer Bedrooms X en o —.
PLOT PLAN 4✓ \, L
Draw a dimensional plot plan,
including: at'
Q
U Precise location of test 'Vdt, 'J" s C
holes,r � f + 1 'nPr�
measured showing distances to '
property boundaries. l //q 1� �t I`
❑Entry road;other roads, n, Wrrl�Y/ / �j �
driveways. T h / [
NOTE: DO NOT DRAW INS
'
SYSTEM DESIGN
pee / 1�_T
OFFICIAL USE ONLY. 0 NOT WRITE BELOW DOUB E LINE. '
SOIL LOGS
'r 1 - 4 t\3"�ltietiz\Thll.7 3 77®ll eo %nt d J (eYe
'Cl4 -a- 1-1 ftkQtekraL wdh bands /oesie d64I
rkl'
hl3 --*Th eC�if5ea c d rzvel tit# ttw
Depth fror Original
Grade to I estrictive
Layer or d ater Table: In.
DESIGNER DESIGNATION SCORES MINIMUM SYSTEM REQUIRE IENTS
etlVI4`/� Design:O Level One Level Two
Soil E is \
` q 0 SepticTank Daily
Vertical Separation O J{
i \� Capacity: Gal. Flow: �' GPD
Slope
Appl. Infilt. ep rom orIginaIq, çp,
Parcel Size p����
Rate l3PD/FT Area f Grad to Bottom of
/ C O ) Abso Dtion area:
Distance to Shoreline __ _ Total Inspector e O� S Date
) [�L�• C
COMMENTS/CONDITIONS FOR APPROVAL
(t ) ��a`�r��ppaosr SE kenk end Oa rm all 2r ak ) ump Rv 1;
) �l�rl�' asne6' p in ston infot�rr dry 1�
( ) NbQ Wons*aek,o Q,lo1O &d m a `resLOr Ne A«t 1e � ,,le .
On s501A �1e1 hiat 'o,� }lam. *ek1... Y o fan k 1
❑Owner/Designer/Installer must meet on site to verify precise system layout ❑Owner mutt arrange pre-installn conference with health dept.staff
❑Winter observations required U Extreme care needed during site preparation to reserve existing topsoil
Any change from the specified use of the property or any site alteration affecting the system design may invalid to this permit.
This Permit expires 3 years from date of Issue.Denial of this permit may be appealed to the Health Officer withIi 10 days of denial date.
SITE: Approved J(Design Required U Not ed DESIGN: U Approved U Not Approved INSTALLATIONA Approved U Not Approved
BY: ( DATE: BY: DATE: BY: DATE:
TOP: Health Dept. Copy MIDDLE: Designer's Copy BOTTOM: Applicant's Copy