HomeMy WebLinkAboutSWG Application - 3/31/1993 ON COUNTY DEPARTMENT OF HEALTH SERVICES P`-.iMR NO. c
SITE EVALUA DESIGN AND INSTALLATION g $
426 W. CEDAR/P.O. BOX 186/SHELTON,WA 98584 Receipt No.-d�"r�" Receipt No. E. SL
PHONE (206)427-9670 Amount$ Amount$ '^
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PROPERTY OWNER DATE: (— - 2 CHECK APPLICABLE ITEMS ✓ 3 m
INSTAWNG NEW STEM m
PROPERTY ADDRESS: P Sy_
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ONE: R
l/✓� of ��D j44Z,(, —7W3 REPAIRING OLD SYSTEM * m,
CITY: 2y Dl-�S tTE'�S1D-77 L.�SY P SINGLEEXPAN FAMING LY
t+Y� Q,/„ SINGLE FAMILY 'o
SPECIFIC DIRECTIONS FOR LOCATING SITE: OTHER �t i°
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SPECIFY,
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PRIVATE WELL � v
.Te/*7-db4& PU c scm D NUMBERSYSTEM I m
SYSTEMNAME \ \
� APPLICANT
NAME
Name of Lot gp ft.x 4w tL MAILING ADDRESS 1 r
Installer r"`. / Size: �'F saes A. '
Number SIGNATURE 5 a
Name of W X ,
Designer �� �� rooms
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PLOT PLAN
Draw a dimensional plot plan, et,([pE�jAC
including: \ ( m
❑Precise location of test holes,shoving
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measured distances to property hounder ww
ad05.
O Entry road:other roads,driveways.
NOTE: DO NOT DRAW IN I '
SYSTEM DESIGN P ` ✓O ' h, I�
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OFFICIAL USE ONLY. DO NOT WRITE BELOW DOUBLE LINE. J
SOIL '�,� MINIMUM SYSTEM REQUIREMENTS
Tu A; O— 36, $w+ qq R
LO o-�.r.Q Ur�& Design:O Level One 6LOvel Two $
'aL4 Gr /Na.-�/ h J
�� Septic Tank Depth from Original C
a0 Capacity:L -00 Gal. Grade to Bottom of d
/� n Absorption area: 2 an.
a Lo ate— �T Daily APpl. Inflt
GP Rate 0. 9- GPD Area ,C13
za + rN+-rAr T''ll nicw 2-o Inspector Date
V Ted A7' 2� '', Separation q , ! a3 9Z
COMMENTS(CONDITIONS FOR APPROVAL: nn
Sl'' (7 row...Q w�a,r vw�rE b¢-. Ga�raXg¢,dC .
(IDner/Designer/Irstaler must meet on site to verify precise system layout net must arrange pre-installation conferences with health dept.staff
❑Winter observations requiredxtreme care needed during site Peparati n o preserve existing topsoil
Any change from the spedfied use of the pro any site alteration affecting the system design m I date this permit.
This Permit eX Ires 3 sera ftam date of Issue.Den is rmit ma bee led to the Health Olfl r 10 days of denial de
SITE: Approved O Not proved DE G Approved ❑Not roved INSTA TI - Approved ❑Not App
BY: �DATE:I y� 9 BY: DATE: i,1(� BY: DATE,
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