HomeMy WebLinkAboutSWG93-1217 - SWG Application - 9/10/1993 E�
MASON COUNTY DEPARTMENT OF HEALTH SERVICES PERMIT NO. SWG — y
4�C W. CEDAR/P.O. BOX 1666/SHELTON, WA 98584 Date y, o
PHONE (206) 427-9670 Amoul nt$o
z F
rn L . sSG/ S'-a5=-73 CHECK APPLICABLE ITEMS ✓ m
MAILING ADDRESS: DAYTIME PHONE: INSTALLING NEW SYSTEM o
144A5- E• l 8 �* ST r REPAIRING OLD SYSTEM
CITY: STATE: ZIP EXPANDING SYSTEM m
(, Cdm V 10 ?go 7.2 SINGLE FAMILY
PROPERTY ADDRESS: OTHER Z
SPECIFY: 3
SPECIFIC DIRECTIONS FOR LOCATING SITE: PRIVATE WELL f� m
S �� s �� 7 ' [� PUBLIC SYSTEM
SYSTEM ID NUMBER
�C✓ r O r4oer- V. LO1- r� SYSTEM NAME y
^ �. %� APPLICANT �N
NAME I�
Name of Lot _ft.xft. MAILING ADDRESS
Installer M (`�
C Size: S•�L7 acres 4
TELEPHON
Name of E 75= :5
�7 �G�%GrO um SIGNATURE
Designer "7' Bedrooms 3 X „�w.� 0
PLOT PLAN 3yy5( (�L4/'G `fAG a/d gnadCl Pi7(•
Draw a dimensional l�osala�, UX(( 6 00240A W r(1 I'7
including: �(•�`•II Ia —( -7S3
�n� IS�(rF%C m [�
UPME-ise location os ^' �_' " k �(4C�N17�• x I�`
holes,showing s C" a O
measured distano rn i p r rqy.
property boundariprD 00 c
i�try road;other r I�driveways. Cl- C� /
i1 W
NOTE: DO NOT D�IN Cn
SYSTEM DN rs �Q99t
OFFICIAL USE ONLY. DO NOT WRITE BELOW DOUBLE LINE.
SOIL LOGS
Depth from Original
Grade to Restrictive
Layer or Water Table: In.
DESIGNER DESIGNATION SCORES MINIMUM SYSTEM REQUIREMENTS
Finding Score Designer Level: ❑One wo
Soil Type 110?_
Vertical Separation kin Septic Tank Daily
Capacity: /a (o M Gal. Flow: 'U GPD
Slope _ _�
�. Appl. � Infilt.
Parcel Size SIWAc. -S� Rate GPD/FT' Area (000 FTz
Distance to Shoreli—n ogla _Q Total in Date
g
COMMENTS/CONDITI NS FOR APPROVAL
)cip2 Be-,,or� i0i RAC' �s�
Any change from the specified use of the property or any she alteration affecting the system desiggn may invalidate 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.
SfIE:O Approved )LDesign Required ❑Not Approved DESIGN: O Approved ❑Not Approved INSTALLATIOWL)Approved ❑Not Approved
BY: C DATE: 1_ BY: DATE: BY: DATE:
TOP: Health Dept. Copy MIDDLE: Designer's Copy BOTTOM:Applicant's Copy
• /a• I 3P�,NIN� ' �E STATgF U7V OUV�O� IJ��� I
"To Provide Faster Service
'ys saaa aw° at Lower Cost" +
I '
T. s FILE a
o► yR<ipLR US5C1 '
i PLEASE NO REPLY
- ❑ REPLY BY: ❑ REQUIRED
M TY1 T #3
iMCliAK
7ki*�I � i -ynt aT {oFrrvN }2oOT 1
z�0� �
.>T.7F:ui.' Tv✓2 k- "�.� 1} 1.GP'rv'>, :. .
WeAl sTxo(!WKOD
�Y2QPiTl�
36 53"CAPtUe uy (-o; I WAS «a
moil - Q.l c tie rN Ptr)efS
i
�GYarT No FOR TT+F
URE PHONE NO.
T
r
- - -
SIGNATURE PHONE NO. DATE
i f '
a e4Mt•�'[� �. !it �" € t!2 .7, Y1x
C2Rl61NATOR; t. SEND.WH;;�. 1 KECLow cC»IES t?RECIPIENT RECIPIgNf REri7RN V rOw ct71 CtP A REP@VI$`P7EC(a SARY-
MASON COUNTY DEPARTMENT OF HEALTH SERVICES PERMIT NO. SWG
d y
426 W. CEDAR/ P.O. BOX 1666/SHELTON, WA 98584 Date y' o
Receipt No.
PHONE (206) 427-9670 Amount$ m f
PROP WNWI CHECK APPLICABLE ITEMS ✓ m m
( ' 10— 3 INSTALLING NEW SYSTEM f�
MAILING ADDRESS: DAYTIME PHONE: 4/ REPAIRING OLD SYSTEM
�� I a7 EXPANDING SYSTEM w
CITY: STATE: �� ZIP: SINGLE FAMILY
PROPERTY ADDRESS: OTHER c
SPECIFY: 3
SPECIFIC DIRECTIONS FOR LOCATING SITE: PRIVATE WELL
From ho j —T-RHd KD, FOI( PUBLIC SYSTEM i
SYSTEM ID NUMBER
TRh 'iger l&fI'd �' FilS LQ 5f SYSTEM NAME
,leAPPLICANT
rid o riY[r /QCLE NAME
Name of y� Lot �� ft. x �� ft. [LING ADDRESS
Installer ����G� V q
Size: —acres TE EPHONE <.
Name of NATURE 0
���y1 A um er o
Designer . _DL/r l )(�� Bedrooms X
if iS [MO/Ked Gam
''!/ Wilms
PLOT PLAN
�.os �f%/cs Lafrn on W• �r 15
Draw a dimensional plot plan, I A 0Rj9A1 E FYR 6-5 C
including: o
,.,rtlC/ x
6.rlse location of test 9
holes,showing �.b
measured distances to Z o O property boundaries. C e
� � r
9fntry road;other roads,
driveways.
NOTE: DO NOT DRAW IN
SYSTEM DESIGN
OFFICIAL USE ONLY. DO NpjWSLjEAELQHLDQWLF LINE.
. 7 \
0v7
3 �
�
\ .
* .
, . -
,
-
_� � q
\ �
,
�
p�4J�
� a $
. $
! � y
cy, . °� .
C ssao l,•• 'n er+�M•oo•ed
1
• N 1
Uy/r.o , r!
a W i
• I r T (P
i
0
7.
.f L
n e
` 0 01
G, ♦V �
LO
UP
cs
4r @ J
h• Q h a Z __ _ �'�
r wn/1J .p �i -'V LL•S b. J �_ '. ' • N`\ '` P� I
1. 1
J
%,It�•
3 _ho L4 .LZ nl
2
^ • F
CO.
� Yv / D