HomeMy WebLinkAboutSWG2017-00082 TANK ONLY - SWG Application - 4/4/2017 OFFICIAL USE ONLY
MASON COUNTY PUBLIC HEALTH DATE RECEIVED:
ONSITE SEWAGE SYSTEM APPLICATION AMOUNTRECEIVED: RECEIVED BY: � N
PO Box 1666,415 N 6th Street,(Bldg 8) Shelton WA,98584 < CO)
Shelton:360 427 9670 ext 400 Belfair:360 275 4467 ext 400
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APP CANT SS PHONE a a
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MAILING ADDRESS-STREET,CITY,STATE,ZIP CODE r
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SITE ADDRESS-STREET,CITY,ZIP CODE �
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NAME OF DESIGNER PHONE
NAME OF INSTALLER PHONE I�j
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CHECK ALL APPLICABLE ITEMS DRINKING WATER SOURCE I�
❑ NEW CONSTRUCTION ❑ RV HOLDING TANK ONLY ❑ PRIVATE INDIVIDUAL WELL <
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❑ REPLACEMENT SYSTEM ❑ INSTALLATION PERMIT ONLY ❑ PRIVATE TWO-PARTY WELL Z
❑ TABLE 9 REPAIR ❑ SINGLE FAMILY ❑ COMMUNITY/PUBLIC WATER SYSTEM
SeTANK(S)ONLY ❑ COMMERCIAL SYSTEM NAME:
❑ UPGRADE TO EXISTING ❑ OTHER: BEDROOMS LOT SIZE I�
❑ EXISTING FAILURE "Record Drawing required
for aft installations" r A�
DIRECTIONS TO SITE-BE SPECIFIC AND ADVISE OF ANY NEEDED INFORMATION FOR ACCESS(ex.locked gate) n r
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SITE MUST BE FLAGGED FROM MAIN ROAD AND TEST HOLES MUST BE FLAGGED WITH TEST HOLE NUMBERS vi
OFFICIAL USE ONLY BELOW THIS LINE
UPGRADE/FAILURE SOURCE(for reporting purposes)
❑VOLUNTARY ❑MAINTENANCE/PUMPING ❑BUILDING PERMIT ❑HOME SALE ❑COMPLAINT ❑OTHER:
INSPECTOR SOIL LOGS COMMENTS 1 CONDITIONS
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SOIL CODES:
V=VERY G=GRAVELLY S=SAND L=LOAM Si=SILT C=CLAY E=EXTREMELY R=ROOTS
INSPECTOR SIGNATURE DATE APPLICATION EXPIRATION DATE APPLICATION APPROVED BY DATE
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THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE REVISED 3/2/2015