Loading...
HomeMy WebLinkAboutSWG95-0269 - SWG Application - 4/26/1995 MASON COUNTY DEPARTMENT OF HEALTH SERVICES PERMIT NO. SWG — y S m 426 W. CEDAR/P.O. BOX 1666/SHELTON, WA 98584 Date S Z o PHONE (206) 427-9670 Receipt mo lnf$°' Z 0 w F OWN CHECK APPLICABLE ITEMS ✓ L •' r m m MAILING DRESS: �YTIME PHONE: INSTALLING NEW SYSTEM o _ REPAIRING OLD SYSTEM CITY: STAT nn ZIP: EXPANDING SYSTEM d /t. SINGLE FAMILY PROPERTYADDRESVC OTHER A&MAJ9 P4 Z aJQ . SPECIFY: 3 SPECIFIC DIRECTIONS FOR LOCATING SITE: PRIVATE WELL S PUBLIC SYSTEM -v�Lcr� � SYSTEM ID NUMBER tc M SYSTEM NAME ob ` APPLICANT 17� ''//w kTELEPHONE kr 1 InstallName er otft7 ' �� • S , 1� Size: acresq Name of - Designer Number o Bedrooms PLOT PLAN Q� //� y q 1011 Draw a dimensional plot plan, "� 6,mdek A� ��. EI �� JOD including: m ❑Precise locati t V (�(,'c%• sy tst 0 1© holes,showin rnab 7 0- 10 measured dis nces to > l/ property bou VJ 10 ❑Entry road;o ds, CC driveways. � , � ` U NOTE: DO NC7$', w is:jj �1 SYST SIGNzi r�rJY� .Z-WFICIALTSE ONLY. DO NOT WRITE BELOW DOUBLE LINE. SOIL LOGS _ T Depth from Original Grade to Restrictive Layer or Water Table: In. DESIGNER DESIGNATION SCORES MINIMUM SYSTEM REOUIREMENTS Finding Score Designer Level: ❑One ❑TWO Soil Type Vertical Separation in. Septic Tank Daily Capacity: Gal. Flow: GPD Slope % Appl. Infilt. Parcel Size Ac. Rate GPD/FT7 Area FT' Distance to Shoreline n. Total Inspector Date W 4pl ` y nK Q COMMENTS/CONDITIONS FOR AP ROVAL } n � 6 Drr1/c°CU2 Any change from the specified use of the property or any site alto on affecting the system design inva at hiswrmit) This Permit explres3xears from date of site inspection.Denial of thi it may be appealed to the Health Officer within 10 days of denial Gate. S SITE: Required ❑Not DE pproved ❑Not Ap v INSTALLATIONA Approved ❑Not Approved BY: DATE: BY: DATE: BY: DATE: TOP: Health Dept. Copy IDDLE: Designer's Copy BOTTOM:Applicant's Copy � IN T a - "To Provide Faster Service INCLUDE {p ��r ov at Lower CosT" MAIL Mg.� 'STOPS FILE N PLE REQUIRED REPLY REPL❑ V BY: LJ REQUIRED ` Too oiy n l N1W ry I cr 0 a FAO , wrl 51q � a, t SlGkATUR NE DATE Y ip yam/ O I P 7 r ,<� ICI �t S• c e �5 � 2 � r � 60 SO _ 7 Ah SIGNAT E PHONE NO.� I�EE'C � i tow 5$1E1, Eytyx_ ..q C 4�. y i © s a•" V#1ffi nL!' '` LGOW COkIE84,6 RECIPIENT +_. . s �{ZE f' RF 43R J YBLIOW'COPY'If A REPLY12 R,A}t A+RW ORIGINATOR'S FOLLOW-UP COPY