HomeMy WebLinkAboutRepair - SWG Application / As-Built - 3/5/1968 3ZSNyo �DTRTH ' HEAII CT Ns' y �
Division of Sanitation
Court House Annex Court House annex
Shelton, "ashington Olympia, Washington
Phone 426-8515 QQ E aZ) Phone 352-4851
APPLICATION TO CONSTRUCT OR ALTER AN INDIVIDUAL SEWAGE DISPOSAL SYSTEM
(Application required for each installation)
Property Owner Telephone..#a p lea 3
Pleas Print
Naiiing Address
Address of Site d - -3
Location of Property, including: Lot ; Block,'r` / Other
Detailed directions to site: z
Propertyy Comme ial
Size /S Residen a No. Bedrooms�_Basement,/1 Type Cc u
Water Supply: [!el Spring Other
Is arW water supply or body of water within 50 feet of sewage system? Teo—
No-Septic Tank O�allone. Drainage �jstem Length,„ feet. Trench llidtk.Ft.
(Refer to Table 1 of Bulletin) (Reeler to Table 2 of Bulletin)
And/or system other than above
Check for Installation of:
Automatio Laundry (.X) Automatic Dishwasher (k) Garbage Grinder ( )
Is Contractor installing septic tank? yes No x Drainfield? yes no Y
Name of Sewage Contractor
Sewage contractor must be licensed by Thurston-Mason
Health District
BUTCH PLOT PLAN AND PLANS OF PROPOSED SYSTEM ON SEPARATE SHEET OF PAPER
THE UNDERSIGNED hereby applies for a permit to construct a new Q0 and/or
alter ( ) a sewage system on bo party aaoord ce with the Bulletin.
Applicant's Signature r/ � � r�
Address—& "yk le.-�--- — -- -----
Bulletin, Washington State Department of Health Bulletin No. 1 entitled
Septic Tank System for Your Home for minimum requirements.
-- ---- - - (Not Po filled in b�Applicant)
Permit No _Fee ' Date Issued,
Area_-------- — - - -- Sani 3.ani—r.—.--
Dates Inspected— —�� Remarks GZ _ _mac ,�2,�
Date Approved Approved By _
tartan �—
THURSTON-MASON HEALTH DISTRICT No
Division of Sanitation Court House Annex
5th & Birch Olympia, Washington
Shelton Washington Phone: 352-4851
Phone: W-4407
APPLICATION N'OR BUILDING SITE APPROVAL
`, ) (Submit in trip cate to the Health Dept.)
Owner 11 jl(/ !�`• Phone
State
Ma ling Address City
Builder Address
Sewage on rac r Address_, -
Property resat inC n oc S ubdiv.
Directions to Property
Intended uses o i ings
No. of BedroomsNo. -of Bathrooms se}neg eptic a
Public r W er Supp Edi�ouize --
Type of Soil .• o�
Soil Drainage: Good era a Poor do no app
If building is to be connected to piclic sewer, t ms
DRAW SKETCH in blank space or on separate sheet indicating the following:
1. Property lines and location of house on lot and indicate minimum and maximum
setbacks plus dimensions of lot and all buildings.
2. Location of house and sewage disposal system in relation to streams, lakes,
wells, patios, driveways., underground tanks, water supply tins and ease-
ments.
3. Location of all interception drains or french drains.
4. Proposed fill, including depth, area, porosity and amount.
j Y
i # l
1 � O
APPLICANT'S SIGNATURE ' ' ~ w' DATE 1 T
DON S LINE
Date Approved �?.. /.. dot Approved BY S.
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