HomeMy WebLinkAboutSWG Application - 7/18/1983 FHA/VA CASE NO. DATE 7-It-3-0 AMOUNT j'b. 90 EEC. ,f
Mason , County Health Depart�� t
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E .YUNG,M.D.,N.P.H.,F.A.C.P.M.
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MEDICAL-NURSING SECTION Hnah OHlur ENVIRONMENTA HEALT TION ff
110 Wnt"K"Strwt 303 North 4th ��, �: . ■
ahsho",Wsshihii,on Stilton, (206)4ton 985
561 w
PM1arH 12081426440'! Poone 120611I65581
APPLICATION FOR REPORT ON INDIVIDUAL SEWAGE DISPOSAL SYSTEM AND/OR WATER SUPPLY .. ,
4., r
It is the established prectipe of the Federal Housing Authority and the Veteran's
Administration to obtain information from the local health department pertaining to
the acceptability of the individual sewage disposal systems andlor water supplies.
INFORMATION REQUESTED ON: INDIVIDUAL SEWAGE DISPOSAL SYSTEM Iri WATER SUPPLY
E I�f D a
I ocATED AT: /V rf as / Qr ti fr�, s z b
Number Street Ct / 1 zip
Directions to Property= 0 74a
of Ge✓d
Legal Description: P+A-
owner or Builder: 'To ivl •Spt'nri✓ - Year Hems Built= 9�0
Purchasers //f„Y/�1�1 S�P9��✓
Send Report Tbi Svo / /j9a�l` c Aa B� /Lt o
.Sad �oin7 Ic 7v` v. NV w S:fc O L yBJfS
✓ Signature of Applicant:11• N f' iv. Phones Soy-7 ss- 0Y-;?9
THE SEPTIC TANK MUST BE FtWED AND THE DRAINFIE[D LII'II'8 EXPOSED. A COPY OF THE BILL
FROM THE PUMPER MUST BE SENT TO THE HEALTH DEPARDINP, INDICATING. SIZE OF TANK (IN
GALLONS), CONDITION OF TANK AND DRAIRFIE D. NOTIFY HEALTH DEPARTMENT AS SOON AS
TANK IS OPEN AND DRAINFIE[D EXPOSED.
FOR HEALTH EEPARTMENf USE ONLY DATE RECEIVED ?"t8 �'J .
• . DATE/SITE INSPECTION 7-dS-,F
DATE/FINAL INSPECTION
470 SEWAGE DISPOSAL SYSTEMS
Q HOUSE OCCUPIED HOUSE VACANT
,X It is the opinion of this Health Department that this individual sewage sye
tem is functioning satisfactorily,
Sewage was disebarging on thesurface of the ground
There are indications that this system may malfunction at times .
There is indication of malfunction on nearby properties
Other:
`ff/I;OB WATER SUPPLY2
The supply does conform with "drinking water standards of this department
The water supply does not conform as follows: .
i
NMENl'AL HEALTH D
i 2 33a .7Y 00a3a _
CSTATE OFwASHINGTON OSHS......HIA11 oEPAgTMENT OF S
WATER BA CT OCTAL AND HEALTH SERVICES
sAMPL inslructiDoa a e RJOnot foll,�ONS ON o gG'yA�D gas .
MDNTIaA ;c DAY YEAR
TIME COL E��PIa will ry )FIA)ectetl.
7 I'S E/3 AM f ✓S COUN ME
TYPE OF SYSTEM IF PUBLIC Byy PM
�DBLID $TEM COMPLETE.
f
I�
q INDIVIDAL." ,.
L
a. rID
NAME OF SYSTEM 1 CIRCLE CLRSs
SPECIFIC LOCATION WHFflE
N'E �(9 SAIAPL
riel0 m'.. yqu¢cTEo sv
b4 0V4i"FH•Mck
AD
SAMPLE COLLECTED B 1�
SOURCE TYPE
SURFACE
WELL ❑SPRIN SEND RE
To.IN ulI PORCHggED COMBINATION
" Aeorea
ZIP c.A. or OTHER
. Q
TYPE OF
LEWASHINGT
AlJ DNz
14 DRINKING WATER
check treatment CMon^atetl(ReaitluEH---1• ❑ Filtered Tote'
3. 0 RAW SOURCE WATER Un4eeled or Other
3.
NEW 40 , CONSTRUCTION or REPAIRS
ER ISpeplY)
COMPLETE IF THIS SAMPLE IS A CHECK
PREVIOUS IRS NO.
SAMPLE
R PREVIOUS SAM
EMARK E CO LE CO CT�
4
LABORATORY RES _MPN.COLIFORM OL (FDA --_ _LA8 USE Q 0/S IiO°•wr- STO PLATE COUNT SAMPLE N O qNo)
MPN DI T TESTED
LUTION —�ml BECAUSE:
TEST UNSUITABLE ❑ Semple Too OM I 1
MF �IOO mI 1' � ConllVentGro
OLIFORM wM
Cl Not In Prepay ConMirgr
�/,OO 2' 0 TNTC
FECAL COLIFOR 3. Cl Cl praouVQlcient l f
MPN Excess None tlel—PI .. .Von
ME Inatryetlo^a p^Fono tl
FF0 I m1 4 �—
INKING WA TER SAMPLES O ❑ -
BATISFACTORY ONLY,THESE
SEE REV RESU SFA TSARE
4B� EASE SIDE OF GREEN COP ❑ UNSATISFACTORY
..
Y FOR E%PLANATION OF RESULTS
O'ETE TIME
1E' E•¢ -5(��O gECE1VF0_ RECEIVED By
DATE pV iN`l^u7- 19S
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REMARxB N
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