HomeMy WebLinkAboutSWG Application - 12/4/1957 TEURSTON-MASON DISTRICT HEALTH DEPAH'PMENT
Court House Annex Division of Sanitation Court House Annex
Shelton, Washington Olympia, Washington
Telephone 6-8515 Telephone 2-4951
APPLICATION TO CONSTRUCT OR ALTER AN INDIVIDUAL SEWAGE DISPOSAL SYSTEM
(Application Required for soh./Installation)
Property Owner. 87t/fo7� Jchuo / �6 / Telephone
(Please Print)
Mailing Address
Address e / d.l of Site ia"---.- C-
Location of Property, Including: Lot #_lock #fther
Ld.etailed direeticaa to 6110
Property Commercial
Size Residence_No. Bedroome_Basement Type
Water Supply; Public, Well_, Spring_, Other
Is any water supply or body of water within 50 feet of sewage system? Yee No
SKETCH PLANS AS DESIGNATED ON BACK SIDE OF THIS)SHEET.
"'X n
Septic Tankgallone. Drainage System Length fast. Trench Width��Snehea .
And/or other F.H.A: Yee__No_.
Check for In-
stallation of: Automatic laundry ( ), Automatic dishwasher ( ), Garbage grinder(
Is Contractor installing septic tank? Yes_Noj_; Drainfield? Yes*No_.
Name and address of /
Sewage Contractor: l- /dal , S ?o .-✓; c e
THE UNDERSIGNED hereby applies for a permit to conatruct a new ( ) and/or alter
a sewage system on above property. The construction and specifications are to be in
accordance with the "Minimum Requirements and Standards Regulating Sanitary Sewage
Disposal in Thurston-Mason Countlee". .
8 ignatant°e 0 .Gc G�J' "�Signature:./!1 /`o!,`fddareesi
NOTE; Please refer to "Minimum Requirements and Standards Regulating Sanitary Sewage
Disposal" and the accompanying drawings.
(Not to be filled in by applicant) 1
Permit No " 3g8 Fee $5_00 Date issued By �z O �� +
Area Sanitarian
Dates inspected 7 Remarks ) �j
Date approved Approvedby1
Sanitarian
(OVER)
SRETOH AND DESIGNATE THE FOLLaMIG:
I. Property lines and names of streets.
2. .Locate all buildinge, driveways.,::septic tank and/or other, drainfield, h
distribution box and trees. aF
3. Dimensions of septic tank and drain£ield.
4. Location of and distance to any stream,--lake, Puget. Sound, or� other 1.
bodies of water within 100" feet of sewage system.
5. Location and type of wells or other water eupplies within IDa feet
of sewage system.
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THURST_ON-MAuON DI$TRIW
.... ' - DEPARTN W OF HEALTH
MEMORANDUM
TO:
'RECEIVED IT!:
DATE & HOUR: --------.
NAME:
REPORTED BY:
ADDRESS:
ACTION TAKEN:-
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