HomeMy WebLinkAboutSWG97-0114 - SWG Application - 3/17/1997 1
MASON COUNTY DEFT. OF EEALTE
Field Sheet for SWG# a7 0 I1 y
Applicant Name: k
Were any of the following conditions observed while conducting the
on-site sewage permit evaluation?:
Yes No
1. Steep Slopes > ls%
2. Water
a. Wetlands
b. Streams
c. Lakes
d. Ponds
e. Saltwater
3. B Eagle Territory ..-
Date
rlan's lgnature
rc Gx MLVM r IVIV MnILI NIJI'VJAL t'CfSllyllI
MASON COUNTY DEPARTMENT OF HEALTH SERVICES' PERMIT NO. SWG!R
— S
426�DAR/P.O. BOX 1666/SHELTON, WA 98584 Data tj Q 4 _: y
o
PHONE(360)427-9670 Receipt No._Amounts `o 1 'z e
G�� CHECK APPLICABLE ITEMS ✓ m
�•cl1CN �'ml.n n 'Lu � 3-10-47 m
AAILIN DRE DAYTIME PHONE; NEW SYSTEM 3< o
REPAIRSYSTEM a
;ITY: STATE:� MAINTENANCE REVIEW F, d
V WK SINGLE FAMILY V
'ROPERTY ADDRESS: OTHER a z
�— SPECIFY: H 3
SPECIFIC DIR�TIONS U
FOR LOCATING PRIVATE WELL $
t PI ESITE: , C• COMMUNITY WELL/PUBLIC SYSTEM
all
SYSTEM WFIIf N I•�
SYSTEM NAME
APPLICANT IN
NAME J IW
Jame of F DcohGf� Lot ft.x ft. MAILIN AD"DRESS
Jammistaller
Size: 03 acres o
lame of �' TELEPHONE O s. I^
)esigner um ro SIGNATU o
- L7 Bedrooms X r,
2LOT PLAN II v
)raw a dimensional plot plan, I IN
icluding: �$ �
S Precise location of test ZS
hales,showing o I o
measured distances to rp
property boundaries. qb, —o t o n
Ontry road;other roads, te���N .1o,T �a 5� 129$/ s
driveways. i-�
TOTE: DO NOT DRAW IN
SYSTEM DESIGN /I
VIOCHMIL . I .
OFFICIAL USE ONLY. DO NOT WRITE BELOW DOUBLE LINE.
SOIL LOGS
Depth from Original
Grade to Restrictive
Layer or Water Table: in.
DESIGNER DESIGNATION SCORES MINIMUM SYSTEM REQUIREMENTS
Findin Scere Designer Level: ❑One O Two
Sail Type _
Vertical Separation in. Septic Tank Daily
Capacity: Gal. Flow: GPD
Slope x Appl Infilt
Parcel Size Ac. Rate GPD/FTr Area FT'
Distance to Shoreline It. Total Inspector Date
COMMENTS/CONDITIONS FOR APPROVAL
411 septic systems must be designed and installed by contractors certified by Mason County Department of Health Services,unless prior approval is
granted by the department,or the design is by a professional engineer.
ieptic permit approval does not imply other building site requirements(i.e. RLC,Water Adequacy)have been met.
4ny change from the specified use of the property or any site alteration aeedIng the system design may invalidate this permit.
this pV_d expires 2 years from the date of site review.Denial of this permit may be appealed to the Health Olflcer within 10 days of denial date.
TE REVIEW: DESIGN REVIEW:❑Approved Not Approved INSTALLATICia9 Approved O Not Approved
y: DATE: BV: DATE: By: DATE:
TOP: Health Dept.Copy MIDDLE: Designer's Copy BOTTOM:AppliranCs Copy