HomeMy WebLinkAboutSWG99-00454 - SWG Application - 12/3/1999 HASON COUNTY DEPT. OF EEALTE
Field Sheet for SWG# /-0-45
Applicant Name: l7h'G uCdZl /
Were any of the following conditions observed while conducting the
on-site sewage permit evaluation?:
Yes No
{ 1. Steep Slopes > 15% '
2 . Water
a. Wetlands
b. Streams
c. Lakes
d. ponds
e. Saltwater
3 . Bald Eagle Territory _
& s
sa tarian's S gn ure Da
PERMIT NO. SWG — rn
MASON COU - D ARTMENT OF HEALTH SER CE o m
Data _ n N
4'6 W CEDAR BOX 1666/SHELTON,WA 98684 Receipt No. o' o
i' E(360)427-9670 .
Amount$ 2 Z F
Pk9PERTY OWNER: DATE.' 0
CHECK APPLICABLE ITEMS $/ 3 m
ING ADDRESS: DAM EP ONE: NEWSYSTEM
G O 4 REPAIR SYSTEM
C h�TATE: R ZIP. TABLE 6REPAIR m
• MAINTENANCE RENEW a
PROPERTY ADDRESS: SINGLE FAMILY v Z
L O L �"� ✓V ORNATE WELL r $
SPECIFIC DIRECTIONS FORLOCATING SITE:
n J�U Nn S'InQ I�D•y I L aV Z . g h MMUNITY WE UPUBUC SYSTEM
SYSTEM WFI p I�
L„ SYSTEM NAME I, r
APPLICANT QJ
NAME C Ir- Jf C-7 Name of Lot 10� ft.x2„�ft. MAILING ADDRESS
Installer A, t o--�ti�"�a ELE r 1 1 7
Size: acres IY(^^
Name of
Designer B Number ot edrooms ,j %IGNA E S rl
OFFICIAL USE ONLY BELOW THIS LINE
DEPARTMENTAL SOIL LOGS DEPARTMENTAL COMMENTS/CONDITIONS f �-
m
I�s II nn
III-^I Imo'
I I�
y
SOIL TEXTURE CODES:
V=Very G=gravelly S=sand L=loam Si sift C=day E=Extremely
INSPECTOR(print name) INSPECTION SIGNATURE DATE PERMIT EXPIRATION DATE
•All systems require ongoing Operation and Maintenance(06M)as specified In Masers County On-Sfte Standards.
•All on-site sewage systems must be designed by a Mason County Certified Designer o a Professional Engineer,unless prior approval is granted otherwise
•All on-sbe sewage systems must be installed by a Masan County Cedihed Installer,unless prior approval is granted othewse.In such cases a preliminary on-slte
meeting between health department staff and the homeowner is required.
•On shesewage system design approval does not imply other building site requirements(i.e.RLC,Water Adequacy)have been met.
•Any change from the specfied use of the property or any site alteration affecting the system design may invalidate this Permft.
This permit e ices 3 yeas from the date of site review.Denial of this permit my be appealed to the Hearth Officer within 10 days of denial date.
DESIGN REVIEW APPROVAL BY: DATE: INSTALLATION APPROVED BY: DATE:
TOP: Health Dept. Copy MIDDLE: Designer's Copy BOTTOM: Applicant's Copy