HomeMy WebLinkAboutSWG2006-00330 - VAR Application - 4/16/2007 ONSITE SEWAGE SYSTEM APPLICATION
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426 W.CEDAR STREET PERMIT NUMBER: S �8a(p ���� a a
PO BOX 1666 L.
SHE ON,WA 98584 DATE RECEIVED: IY AMOUNT RECENED:EJ N m
(360)427-9670,Ext.352 0 tl1
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APPLICANT DATE CHECK APPLICABLE ITEMS Z E
D NEW SYSTEM 3 O
D REPAIR SYSTEM m
MAILING ADDRESS DAYTIME PHONE D TABLE 6 REPAIR C
2�42 / A -�d, WXy/v O D TANK REPLACEMENT
CITY STATE`T ZIP D �mqHOLDING r)TANK ONLY pcc
AL /- �/�, /` 9/�l D INSTALLATION PERMIT ONLY K n
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SITE ADDRESS D SINGLE FAMILY Z
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NAME OF DESIGNE PHONE NUMBER O
`_ A . QkI ,' 7,?— 61Q{0 DRINKING WATER SOURCE 0
NAME OFINSTALLER D PRIVATE INDIVIDUAL WELL 1 .1
D PRIVATE TWO-PARTY WELL p f
WA144tlV excwjc.*b- D COMMUNITYIPUBLIC WATER SYSTEM IN
NUMBER OF BEDROOMS LOT SIZE: ACRES FT FT SYSTEM WFI#.
0 CD SYSTEM NAME:
SPECIFIC DIR�EnCTIO(NL,S FOR LOCATING SITE.4
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Site must be flagged from main road and test holes must be flagged with test hole numbers
Official use only below this line
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INSPECTOR SIGNATURE DATE DESIGN EXPIRATION DATE DESIGN APPROVED BY DATE
INSTALLATION FEE PAD) DATE INSTALLATION EXPDIATIONDATE INSTALLATION APPROVED BY DATE
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