HomeMy WebLinkAboutSWG Application - 3/17/1975 P.O. Box WA. THURSTON-MASON HEALTH DISTRICT No. ) �`e e
phone:4 WA. g8584 4th 6 Brenner
Phone: 426-44D7 DIVISION OF GNVIRONMENTAL HEALTH Olympia,NA. 98501
Phone: 753-8073
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owNER C. JAiAP ( n ..",y L: ,i`�i O/',1 PHONE ^... G;-/-) 1i 86
OWNER"S ADDRESS �-2IA t� � /I!' ; T CITY /)p n STATE 11 ?0.
SEND REPORT TO ` I CITY STATE J/
SEWAGE CONTRACTOR I-1tJc:J/1"@ ^. .. /j: „1 N ADDRESS
(If a If c er w th E.H.Sl )
LEGAL DESCRIPTION �1 '1 @IE /)S:�
.BA' BIfrPO. LOT SIZEI0 N 1-7 1 INTENDED USE OF
NO. OF BEDROOMS J NO. OF BATHROOMS BASEMENT PLUMBING: Yes_NR Jt
WAME OF WATER SYSTEM" �'�./�(_r_• a ;-/,r,p INDIVIDUAL PUBLIC_OOMl53NITY
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DIAECTIONS TO PROPERTY: (Be Specific) I ~� \O/j ,i
DRAW A SKETCH SHOWING: 1. Property lines, location of house on the lot, and dimensions of the
lot. 2. Location of the house and sewage disposal system in relation to streams, lakes, wells,
soil log holes, patior driveways, underground tanks, water supply lines and easements.
The septic tem L d taapora method of sewage disposal
DO NOT WHITE IN THIS SPACE
MINIMUMS: /
Septic Tank ! e� �r
Drainfield `� 7--
SITE APPLICATION Y
APPLICANT'S SIGNATURE / DATE 3 -IJI ' 17S
SITE INSPECTION
VIA CTIOINSPECTION �l FEE,1j RECEIPT NO. b IN 4 BY 0 0
APPROVED/7 9 7 S—�� APPPJVED E
Data Inspector/E.H.S.
_ SEWAGE APPLICATION / / NEW / / ALTERATION
APPLwwICANT'S SIGNATURE DATE
.� FEEp� RECEIPT NO. BY J` _
PERNIT NO. APPEJVE11 xm- ✓`' �' (• �,
Date Inspector/E.t1.5. /
ya01a'Ss• 0-0009