HomeMy WebLinkAboutSWG92-227 - SWG Application - 3/17/1992 PERMIT NO.
MASON COUNTY DEPARTMENT OF HEALTH SERVICES Exmi�:�
DESIGN AND INSTALLATIONDate426 W. CEDAR/P.O. BOX 186/SHELTON,WA 98584 Receipt No. 0 u;
PHONE (206)427-9670 Amount$ Amount$ m m
PR RTY O s N DATE:kfA CHECK APPLICABLE ITEMS ✓ m
' INSTALLING NEW SYSTEM
MAILIN A ESS: DAYTIME PHONE: O•
3 REPAIRING OLD SYSTEM
CI STATE: 1AT / EXPANDING SYSTEM
Gt'D "� SINGLE FAMILY
OTHER Z
PROPER ADDRESS:
SPECIFY: 3
PRIVATE WELL m
7%W=WCATI G SITE PUBLIC SYSTEM
HAWY SYSTEM ID NUMBER I�
SYSTEM NAME h.
APPLICANT
'I NAME
Name of O Lot ft.x UO ft. MAILING AD R SS I W
Installer Size: acres ® I�
Name of SIGNA URE
Number of
Designer Bedrooms Ix I W
PLOT PLAN I eA
Draw a dimensional plot plan, /
including:
❑Precise location of test 6TO
holes,showing
measured distances to 6 �T l7�✓ M A R 1 7
property boundaries. /
❑Entry road;other roads,
driveways.
H w3 ~
NOTE: DO NOT DRAW IN PITE
4 w�11 be
SYSTEM DESIGN OFFICIAL USE ONLY. DO NOTELOW DOUBLE LINE.
SOIL LO S)�j� MINIMUM SYSTEM REQUIREMENTS
t/v
211' f' ( verl�Ow1 > Design:J�LevelOne ❑Level Two
"1/7 ell xt� t an
(�j`� fL9 Se tic Tar�c Depth from Original
QnCapa ity:57f f G L Grade to Bottom o .+-
Absorption area:�ln.
� ?( t�yq-1 ok�,rs�rr� a end• /yI�eL�� �r��� �P
3��/ 1'l �`J r• �e tC N�.I / 7G ,l>Li Daily J//p APPI• J)/ Area
Flow /V GP Rate �(�/ PD/FTz Area �`
Vertical Inspector
Separation
M NTS/CO DI O S OR PPR VA
5 sol to s7�f� r1eu� � '(� 1A tc� b � . in-
) z�l� ��-)� �Syrr� /o� �1f s 7 -71 /It9cu �1l friZ�'es �� 1�
�n s 0J(S'���encens
❑Owner/Designer/Installer must meet dh siI verify precise tem layout ❑ ner must arrange pre st�lahon conferences with health dept.staff
❑Extreme care
❑Winter observations required needed during site preparation to preserve existing topsoil
Any change from the specified use of the property or any site alteration affecting the system desiggn�-�may invalidate this permit.
This Permk ex Tres 9 ears from date of Issue.Denial of this @ ma be a led to the Heakh Omcer within 10 d s of dental date.
SITE: roved ❑Not App v DE SI N; Approved ❑Not Ap v INSTALLATION:❑Approved U Not DATE:
BY: DATE: 3 BY: l DATE: BY:
TOP: Health Dept. Copy BOTTOM:Applicant's Copy