HomeMy WebLinkAboutSWG92-0739 - SWG Application - 9/28/1992 N COUNTY DEPARTMENT OF HEALTH SERVICES PERMIT NO. rtJ 1 -
SITE fA I DESIGN AND INSTAI TION
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426 W. CEDAR/P.O. BOX 10//SHELTON, WA 98584 Receipt o. Receipt No.
PHONE (206)427-9670 Amount$ 00 Amount$
PROPERTY 0 a c S • 2? _ 93 CHECK APPLICABLE ITEN 3 V m
G NEW SYSTEM
MAILING ADDRES DAYTIME PHONE: INSTALLIN m
REPAIRING OLD SYSTEM
ITY: STATE: ZIP: EXPANDING SYSTEM
98S-).}Z3 SINGLE FAMILY m
PROPERTY ADDRESS: OTHER 4 Z
C a 0"
SPECIFY: 3
SPECIFIC DIRECTIONS FOR LOC TING SITE: /4 a//, deY L7c2 h. PRIVATE WELL m
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!., SYSTEM ID NUMBER j�
Sa Pltr7 .Las7 0Af K SYSTEM NAME LQ�
APPLICANT
NAME rJs p oc
Name of of .Sd r ft.x /GSA ft. MAILING ADDRESS B, 0 75
Installer So/ ize: r acres A Cd". 9flfa o
TELEPHONE o 2
Name of um er o SIGNAT �p/ o
Designer edrooms Z ftcIr-sa .r, X UR �<re a (�
No �csr
PLOT PLAN
Draw a dimensional plot plan,
including:holes,showing a O In_
❑Precise location of test �ResC�T Z F ( v
measured distances to V II a
property boundaries.
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❑Entry road;other roads, ii vv
driveways.
NOTE: DO NOT DRAW IN
SYSTEM DESIGN
OFFICIAL USE ONLY. DO NOT WRITE BELOW DOUBLE LIN .
SOIL LOGS
Depth fror Original
Grade to I estrictive
Layer or d ater Table: In.
DESIGNER DESIGNATION SCORES MINIMUM SYSTEM REQUIRE NTS
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Design:❑ ne ❑Le o
Soil I
Vertical Separation Septic Tank Daily
Capacity: 0 0 Sal. Flow: GPD
Slope
Appl. Infilt. a rom Original
Parcel Size Rate GPD/FT' Area rad to Bottom o
Abso do In.
Distance to Shoreline Total _ Inspector Date
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(4An (0 ca n s. O M &rT1S/OONDITIONSIc O®A RQYAL
❑Owner/Designer/Installer must meet on site to verify precise system layout ❑Owner must arrange pre-installation 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 invali ate this permit.
This Permit expires 3 years from date of Issue. Denial of this permit may be appealed to the Health Officer withi 10 days of denial date.
SITE: ❑ n Required ❑Not ed IDESIGN: Approved ❑Not Approved INSTALLATION:❑A proved ❑Not Approved
BY: DATE: qy BY: ' DATE: Z y BY: DATE:
TOP: Heath Dept. Copy MIDDLE: Designer's Copy OTTOM:Applicant's Copy