HomeMy WebLinkAboutSWG94-1048 - SWG Inactive - 8/19/1994 MASON COUNTY DEPARTMENT OF HEALTH SERVICES PERMIT NO. SWG y
426 W. CEDAR/ P.O. BOX 1666/SHELTON, WA 98584 Date �l y' o
PHONE (206) 427-9670 Receipt No. y
Amount$ Z
I m �
ea J e / / d 9 CHECK APPLICABLE ITEMS m m
MAI G ADDRESS: ,�,[/ DA IME PHONE: IN I R
ANiT�°A UQ . - IRE4FAIMPIA111CITY: �t TATE: ZIP:PROPERTY ADDRESS: Z
SPECIFY: C/) 3
SPECIFIC DIRECTIONS FOR LOCATING SITE: PRIVgEV*Wt%I- or
,j f 0.7 PUBLIC SYSTEM
SYSTEM ID NUMBER
SYSTEM NAME
APPLICANT I�
NAME 0 PC c f r
Name of MAILING ADDRESS -� \
Installer Lot ft.x ft. N
Size: 02 acres 4
Name of TELEPHONE �
Number o SIGNATURE
Designer Bedrooms X 10,3
PLOT PLAN
Draw a dimensional plot plan,
including: ro
El Precise location of test 00
holes,showing
measured distances to `
property boundaries. 8.
O Entry road;other roads, (�0 1 or
driveways. 1 pp a K R Q
NOTE: DO NOT DRAW IN
SYSTEM DESIGN
PgLqIAL-USE ONLY. DO NOT WRITE BELOW DOUBLE LINE.
SOIL LOGS Tip
i _ Lnnl o����c 7fWm'( a tsar f,4k4
—i _ _y6 5'A�t�Ef�ikAvvl o a y ,.7
c� S4r�. 4 R�RueL f`3
(TY �
Cni
�L7 �
M Depth from Original
Grade to Restrictive
�--.J Layer or Water Table: ` In.
DESIGNER DESIGNATION SCORES MINIMUM SYSTEM REQUIREMENTS
Finding Score Designer Level: ❑One
Soil Type 3 O
Vertical Separation O in. Septic Tank Daily
Capacity: la a Gal. Flow: GPD
Slope O % d
Appl. Infllt.
Parcel Size 2 Ac. 6 Rate GPD/FT2 Area r;G 0 FTz
Distance to Shoreline �I tt. O Total s Inspector Date
COMMENTS/CONDIT16INS FOR AP OVAL
CtCT�EticN��F �Gt� �c2 1.e2 /�Ap/�cAT/�/v l?/�T� �uttl� 5t9kDl 7c�
tL ;3E0 /r �GSS/Sic
Any ch P�e from the specified us'of the pc pperN or�nv gIte alteration ffectinge systero_d� ay invalidate this g�rm�81 date.
This Permit expires es 3 ears from date of s to insp tI n. enia o th�s permit may%e appea ed t0 the Flea tffiWc r within U days Cen
SITE:O Approved ' r ' n Required ❑Not Approved DESIGN: ❑Approved ❑Not Approved INSTALLATION:O Approved ❑Not Approved
BY: DATER-ti-qy BY: DATE: BY: DATE:
TOP: Health Dept. Copy MIDDLE: Designer's Copy BOTTOM:Applicant's Copy