HomeMy WebLinkAboutCRT Application - 1/29/1991 MASON COUNTY
DEPARTMENT of GENERAL SERVICES
Courthouse Bldg.3,426 W.Cedar
P.O. Box 186,Shelton,Washington 98584
(206)427.9670
building environmental health maintenance parks&recreation planning sewer&water
WATER SUPPLY$24.00 SEWAGE SYSTEM S40.00
1) Private Wells 1) If system on record
Water Sample taken by health official; Inspection of Tank pumped; receipt obtained and submitted with
facilities application, then call for inspection
2) Community water system 2) If no system on record
If on an approved community system, no Inspection Tank pumped, receipt obtained, submitted with
or sample Is necessary. However, approval Is application, portion of drainfield lines exposed to
subject to adequate sample history verity size and existence of drainfield
Checks Payable to:
WATER & SEWAGE $54.00 Mason County Treasurer
` APPLICATION"FORAEPORT ON INDIVIDUAL SEWAGE DISPOSAL SYSTEM ANWOR WATER SUPPLY
It is the established practice of many lending Institutions to obtain Information from the local health department
pertaining to the acceptability of the Individual sewage disposal systems and/or water supplies.
INFORMATION REQUESTED ON: )Q INDIVIDUAL SEWAGE SYSTEM ❑ WATER SUPPLY
Locatedat: ,,JAI/ /7 / S a F„ 2 9R' 8'
Number / Street ty Zip
Directions to Property: &PM 4,, 8P1r..Q - i.r- nn� Oin
- LLB -/o -LF/
Leg at Description:
Owner or Builder. 4LO _Year Home Built: i lR Z.
Purchaser. Qpfl,i, P cji(?�n^ Number of Bedrooms:
Send Report to: eon 6rn(nnw. - Zo,d
Name
ilo lsi
S
Address Clty ap
Signature of Applicant: Phone:
FOR HEALTH DEPARTMENT USE ONLY -I
e DATE: I I2 " I(G i FEE h4C) , ��L� RECEIPTA �
SEWAGE DISPOSAL SYSTEM Date—Site Inspection _ �� 25- /h 3
❑ House Occupied R House Vacant Date—Final Inspection
n1 /
zq It is the opinion of this health department that this Individual sewage system Is functioning
satisfactorily at the time of Inspection.
Sewage was discharging on the surface of the ground.
There are Indications that this system may malfunction at limes.
There Is Indication of malfunction on nearby properties.
Other:
WATER SUPPLY:
The supply dtns conform with drinking standards of this department.
Remarks:
0ia.0o '__q .,