HomeMy WebLinkAboutCRT92-0170 - CRT Application - 12/8/1992 MASON COUNTY
DEPARTMENT of HEALTH SERVICES
Mason County Bldg.III 426 W.Cedar
P.O.Box 186 Shelton,Washington 98584
(206)427-9670• Belfaln 275-4467 �Q 1( 'f,.V(
Seattle 464-6968 Other 1 800-562-5628 Cil/ I -1 —61-/
environmental health a persortoil health YNA quality
WATER SUPPLY$40.00 SEWAGE SYSTEM$50.00
t) Private Wells t) If system an record
Water Sample taken by health official; Inspection of Tank pumped,report obtained and submitted with
facilities application;then call for inspection.
2) Community water system. ` 2) If no system on record
If on an approved community system,no inspection or Tank pumped,report obtained,submitted with application,
sample is necessary. portion of drainfield lines exposed to verify size and
existence of drainfield.
r
WATE &SEWAGE$3.00
This is if both water&sewage are done at once.
Checks Payable to:Mason County Treasurer
APPLICATION REPORT ON INDIVIDUAL SEWAGE DISPOSAL SYSTEM AND/OR WATER SUPPLY
it is the established pf*ice of many lending institutions to obtain information from the local health department pertaining to the acceptability
of the individual sewage disposal system and/or water supplies.
INFORMATION REQUESTED ON: �1 INDIVIDUAL SEWAGE SYSTEM ❑WATER SUPPLY
Located at: yqi r .A ri 1 c ` 'Q D i 3£c-- F.4 i %K &j A �T S}.r
Number gym r ZIP
Directions to Property: eR'T F% Owl e9 t z v�" �i+/'� �i� J.T n' �L 1066 Iv a
rop//r��ty: � V.
(2 Y' -r 0 let . 9- P-R t L � tb 9_0 L c r-r' 0 . 5 R'D.) i 3T 'C4 0 fl tl o A.i- L E F T.
Assessors Legal Description: VI t t /a.IG is-S r ^T R st ha-r// I
Assessors'Twelve Digit Parcel Number: � �ALL--/L/)— �L 4/.L -
Ow r or Builder: o nn n 5 iI I -� £ 2 �.�5 oZ�7 Year Home Built:
P aser: 4f r /r Number of Bedrooms: 2
"Send Report to: o - N r IE 10 R J r R 3
o c F l A. ff S
'�.e. 1p $,
'» SlgnaturA~ofAl�plicant: Phone: -'2
FOR HEALTH PEPARTMEWUSE ONLY DATE FEE 396Q RECEIPT# «—_--
SE AGE ISP SAL SYSTEM GAAA68 0 PI-I . � Date—Site Inspection
House Occupied)(House Vacant OW I @n Date—Final Inspection
It is is the opinion of this health department that this individual sewage system is functioning y
satisfactorily at the time of inspection.' .Sly,S7ipt f r "rO /7'0L2 E"//?V'4—/*-
Sewagewas discharging on the suff ; f he g unl9RG�TS
Jere are indications that this system,may malfunction at times. I� � � ,�
There is indication of malfunction on nearby properties. St/��E` CO-
Files have been searched and no records have been found.An on-site inspection revealed no i
apparent system malfunction.Only accessible yard area surrounding the home was inspected. � 1
wo-�0 Other: QAR�a Nidiiii tS $FiA/�- �C A �tikw sl'ej Q:f�" Aq:& _
WATER SUPPLY: NO STH Q- � 1 ' HOi� 00,10H H)}S ep � $Yz�
�g The current omter..-`of the house has cleared ,
The supply does oon orm with d king tan ar s of this department his m i ong i ngs out of• tie-•Aotwe
and into.R&i&kgaraus he is using the setwpe facilities in the house until this loan
doses and he can move.
Signature Date