HomeMy WebLinkAboutswg95-0259 - SWG Application - 4/24/1995 PERMIT NO. SWG Ll
MASON COUNTY DEPARTMENT OF HEALTH SERVICES m
Date 4 2 y' o
426 W. CEDAR/P.O. BOX 1666/SHELTON,WA 98584 Receipt No. Iy
PHONE (206)427-9670 Amount$ m F
P,RQPERTY OWN
�_ �- CHECK APPLICABLE ITEM ✓ m m
ST
MAILING ADDRESS: DAYTIME PHONE: IN ALLING NEW SYSTEM �.
- � � REPAIRING OLD SYSTEM
C STATE: ZIP: EXPANDING SYSTEM m
S SINGLE FAMILY
PR PERTY A ESS: lift OTHER c
O, dW SPECIFY: B
S ECIFI DIRECTI R.L ATING S T PRIVATE WELL CrO�F
0 ' PUBLIC SYSTEM L�
SYSTEM ID NU ER I
t V:T -)i-o 01 1`rl 10 L/t S SYSTEM NAME
APP (CANT
NAME
Name Lot ft.x �� ft. MAILING ADDRESS
LLrir
Installer Size: ' l S acres T LEP ONE
Name of SIG RE
um er o X
Designer Bedrooms I `^
PLOT PLAN
Draw a dimensional plot pla ,, 00
including: y G L
2007 1
❑Precise location of test LU
holes,showing ram! 1
measured distances to a >
property boundaries.
Cr
v
❑Entry road;other roads[!, o LU /v f�
driveways. r--r
NOTE: DO NOT DRANW ELL I
SYSTEM DESI� CC J 2 GU
Q
O
OFF4GIAL USE LY. DO NOT WRITE BELOW DOUBLE LINE.
SOIL LOGS
Am
Depth fro Original
Grade to estrictive In.
Layer or ater Table:
DESIGNER DESIGNATION SCORES MINIMUM SYSTEM REQUIREMENTS
Finding Score Designer Level: ❑One )(TWO
Soil Type _ -21
/� Septic Tank Daily
Vertical Separation m. » Capacity:1,,z 0o Gal. Flow: 3{0o GPD
Slope /b % /0t Appl. Infilt.
Parcel Size s ! Ac. yL Rate , GPD/FT' Area FT'
Distance to Shoreline Total Z Inspector Date
uC14S�Z 9S
COMMENTS/CONDITIONS FOR APPROVAL
Any change from the specified use of the property or any site alteration affecting the system design may inval date this permit.
This Permit expires 3 years from date of site inspection.Denial of this permit may be appealed to the Health Officer within 10 days of denial date.
SITE:O Approved ' n Required ❑Not DESIGN: ❑Approved ❑Not Approved INSTALLATION:O Approved ❑Not Approved
BY; DATE: BY: DATE: BY: DATE:
TOP: Health Dept. Copy MIDDLE: Designer's Copy BOTTOM:Applicant's Copy