HomeMy WebLinkAboutSWG99-00457 - SWG Application - 12/3/1999 MASON COUNTY DEPT. OF HEALTH
Field Sheet for SWGI. 9/ 076�-7
Applicant Name:
Were any of the following conditions observed while conducting the
on-site sewage permit evaluation? :
Yes No
1. Steep Slopes > 15% L�
2.- Water
a. Wetlands _
b. Streams
C. Lakes �—
d. Ponds
e. Saltwater .
3 . Bald Eagle Territory
r S 1 arlan's Sigglafire Date
MASON COUNTY DEPARTMENT OF HEALTH SERVICES R MR NO. SWG off,
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426 W. CEDAR/P.O. BOX 1666/SHELTON,WA 98584 H
PHONE (360)427-9670 ipt unt$o f
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P OPERTV OWN DATE: 3 m
0 /S CHECK APPLICABLE ITEMS �/ m
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AD ESS: DAYTIME PHONE: NEW SYSTEM :
REPAIRSYSTEM
C •;O O STAT 7S 73
ZIP: TA&.E6 REPAIR m
' MAINTENANCE REVIEWfA
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P PE ADDRESS: SINGLE FAMILY
7 )K' OTHER WELL S
SP CIFI IRECTIONS FOR LOCATING SITE: PRIVATE
COMMUNITYWEU/PUBUC SYSTEM
G.a /tatty s.V �'• QUP SYSTEM WRY
L� f SI' rT Ytf r- SYSTEMNAME
APPLICANT V"
O n ?,3hr NAME Lot _ft.x I—
�,�..,,..���� i MAILING ADDRESS p O
Name of � �ft.
Installer l '- ` 1, (`.tj`1:1 Size: acres HOE - 7
Noma of ^ �r um er o SG S h
Desi nor p' (— Bedrooms 3
x
OFFICIAL USE ONLY BELOW THIS LINE �N
DEPARTMENTAL SOIL LOGS DEPARTMENTAL COMMENTS/CONDITIONS
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SOILTEXTURE CODES:
V=Very G=gravelly S=sand L=loam Si=sift C=Gay E=Extremely
INSPECTOR(print name) INSPECTION SIGNATURE DATE PERMIT EXPIRATION DATE
•All systems require ongoing Operation and Maintenance(O&M)as specfied in Meson County On SheStandards.
•All on-she sewage systems must be designed by a Mason County Candied Designer or a Professional Engineer,unless prior approval is granted omerwise
•All on-site sewage systems must be installed by a Mason County,certified!Installer,unless prior approval is granted otherwise.In such cases a preliminary on-site
meeting between health department staff and Me homeowner is required.
•On-she sewage system design approval does not imply other building she requirements(i.e.RLC,Water Adequacy)have been met.
•Arty change from the specified!use of the property or any she afteratim effecting Me system design may invalidate this permit
•Thisft expires 3 from Me date of silo review.Donal of thispermit may be a=Ied to the Health Ofiaa within 10 days of denial date.
DESIGN REVIEW APPROVAL BY: DATE: INSTALLATION APPROVED BV: ^tPATE:
TOP: Health Dept. Copy MIDDLE: Designer's Copy BOTTOM: Applicant's Copy