HomeMy WebLinkAboutWQS Sanitary Survey - 4/10/1996 ON-SITE SEWAGE SYSTEM SURVEY
LOWER HOOD CANAL CLEAN WATER DISTRICT
Project: LEC Area: Date:
OWNER INFORMATION :
/Ve- /40 Guue. "
�e llr,-� WA 9 i526
S INFORMAT7ON• 4 j &0,4s Cnse DtV 4 L&
Parcel A' : i 2 310 - ci - coo 17 Owner's Phone: # LP G s4 e d
Address: NC run hollam /t_!2,� City: State: W _ Zip:
i
Building Type:_ (F-Full iuw Raideoce; S - se.soml Residmce; C -Co®erciel;
M -Multi-family Residence; V - Vacant )
Septic System Type: _ (S - Standard tank.nd dninfield; P - Pmssnro Distntuaoa;
F - sand riiw; M - m md; T - Deep Trench; H- oat xuUSO;
O - Other; U - Unimawn)
Installation Date: Year Last Pumped: (eruer Pear or U- tznkwam)
System Location:_ (F -Front Yud; B - Back Yard; S -Side Yard; A - Adjacent Lot;
U - U kno.)
Number of Residents: Shoreline (Y/N):
OCCUPANT INFORMATION(complete only if diffora t than oa ): -
Occupant's Title: _(am. arts, ars) First Name: Last Name:
Occupant's Phone:
Would you like Information on Water Conservation? (Y"
Would you be interested in a Community Workshop? (Y/N)
PERMISSION FOR ACCESS TO INSPECT THE SEPTIC SYSTEM: (YIN)
SIGNATURE: Date:
Comments:
Area '! Parcel /2 310 - V - QQaL Team f
Nam Address
Phone Number
Site Visit #1 Dated 10,114 Time A: 40
Notes/observations:
dnsalhx
Permission to inspect? Initial
Phone Call #1 Date l (o Time I'M
Notes/Observations:-
T-r, U-"l< 53-ej
No+ VA- T4atiUA
Permission to inspect? initial
Site Visit /2 Date Time , :
Notes/observations:
Permission to inspect? Initial
Phone Call F2 Date Time
Notes/Observations:
Permission to inspect? Initial
Phone Call 13 Date Time
Notes/observations:
Permission to inspect? Initial
MASON COUNTY
DEPARTMENT of HEALTH SERVICES
Shelton.Washington 96584
(360)427-9670• Belfola 2754467
ENVIRONMENTAL HEALTH PERSONAL HEALTH WATER QUALITY
P.O.BOX 1666
303 N. FOURTH P.O. BOX 1666
April 10, 1996
JACOBSON DEBBY
P.O. BOX 40552
Bellevue, WA 98015
RE: Parcel Number: 12330-51-00017
JACOBSON DEBBY,
Our office has been trying to contact you for permission to
inspect the septic system on your property. The inspection
consists of a visual inspection over the top of the tank and
drainfield and a dye test should your system be close to sur-
face water or if there are indications of possible problems.
Enclosed is an informational pamphlet on the survey process.
Please contact us by filling out the enclosed survey form and
returning it to us in the self addressed envelope also en-
closed.
If you have any questions, please do not hesitate to contact
me at (360) 275-8733.
Sincerely,
Grant A. Holdcroft, R.S.
Lower Hood Canal Lead
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