HomeMy WebLinkAboutSWG95-0115 - SWG Application - 3/17/1997 (2) MASON COUNTY DSPT. OF BBAL /` H _
Field Sheet for SWGi{ T—_ [
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Applicant Name: ��k N50tn
Were any of the following conditions observed while conducting the
on-site sewage permit evaluation?:
Yes No
1. Steep Slopes > 15% --V"
2. Water K
a. Wetlands g
b. Streams
c. Lakes
d. Ponds
e. ltwater
3 . d Eagle Territory 1j'7�-�
S rian's signature Date��F-=L—
ON-SITE SEWAGE SYSTEM SITE EVALUATION AtjI_,5_NUSAL rlaHtvu t
PERMIT NO. SWG — c
IASON COUNTY DEPARTMENT OF HEALTH SERVICES
Date 3��--77"T
426 W.CEDAR/P.O. BOX 1666/SHELTON, WA 98584 Receipt• - 1
PHONE(360)427-9670 Amount$ w f
m
CHECK APPLICABLE ITEMS ✓ m m
NEW S SYS
YSTEM
AILING ADDRESS: DAYTIME PHONE:
REPAIR TEM v
STATE: MAINTENANCE REVIEW m
IN: ZIP:
2 SINGLE FAMILY z
r OTHER
ROPERTY ADDRESS: SPECIFY: 3
PECIFIC DIRECTIONS FOR LOCATING SITE: =APPLICANT
S g(yfaS J KG UBUC SYSTEM i`
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e
r y' PEI
G ADDRESS AG 6 ./S I�
lame of Lot 3si X I N R.x N 13� It.
istaller �-. d HONE 3 O S-
Size: / • 3 acres
lame of um r o TIIBF� r \resigner P . I/-CIeJ Bedrooms '1' U[M
)LOT PLAN
N
)raw a dimensional plot plan, 10,E to I 1 s
icluding: O x
d Precise location of test 200-L r�
holes,showing
P� 1 II'F'����777 � 1
r� uL9dW L7t[J � L� U r • •3 �� 131' ty
K oad;other roads, -y
driveways.MAR 131997 / 1
TOTE: DO NOT DRAW IN
HEAL vICEC
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
Rntlin FS—W-rei
Designer Level: 0One ❑TWO
Soil Type
Septic Tank Daily
Vertical Separation in Capacity: Gal. Flow: GPD
Slope Appl, Infilt.
Parcel Size Ac. _ Rate GPD/FT' Area FT'
Distance to Shoreline f, FT-ta-11 Inspector Date
COMMENTS/CONDITIONS FOR APPROVAL
•All 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.
•Septic permit approval does not imply other building site requirements(i.e. RLC,Water Adequacy)have been met.
•Any change from the specified use of the property or any site alteration effecting the system design may invalidate this permit.
•This permit expires 2 years from the date of site review.Denial of this permit may be appealed to the Health Officer within 10 days of denial date.
SITE REVIEW: DESIGN REVIEW:O Approved iNot Approved I INSTALLA ION:O Approved ❑Not Approved
DATE: 8V: DATE: BV: DATE:
r.,m. ue.er, no,., P-,w Mlnnl E- Desimner's Coov BOTTOM:Applicant ,Copy