HomeMy WebLinkAboutSWG Onsite Survey - 5/26/1994 , , 1enr -
R av P 17 •
Tg cl- C' Lg u wai
JUN Q3 I
O3 I -50 - o O z 1993
ON - SITE SEWAGE SYSTEM/Seq. •F
TOTTEN/LITTLE SKOOKUM WAT ' in'!�'V 1 CE
SURVEY SITE ADDRESS sL al T07TEJJ_No 55 13.e
OCCUPANT' S PHONE NUMBER ,,,,,oc,u p.rksp OWN/RENT
OWNER QooGv_,Q„1 /r) 1obbuje fiJ OWNER'S PHONE # p�4,2/3�31
OWNER' S ADDRESS / Qdx c 7 /14.001EiTEe L4 y3.5:7
NUMBt±( u.t RE6IDENTb 0 rarcel# Za?f-�Q—Ooaao
(CIRCLE ONE))
H- HOME F'�I SEASONAL HOME R- RECREATIONAL SITE
C- COMME AL I- INDUSTRIAL U- UNDEVELOPED
M-MULTI FAMILY V- VACANT HOUSE
ON-SITE SYSTEM TYPE Q/� INSTALLATION DATE /9,I
S-SEPTIC TANK PD- PRESSURE DISTRIBUTION D- DESIGNED
C- CESSPOOL SP- SEEPAGE PIT 0- OTHER
OH- OUTHOUSE DT- DEEP TRENCH
PUMPING FREQUENCY (YRS. ) LAST PUMPED (DATE)
LOCATION B y/SY FY- FRONT YARD BY- BACK YARD SY- SIDE YARD
AL- ADJACENT LOT
ANIMALS!) CATS DOGS COWS DUCKS GEESE
GOATS HORSES RABBITS SHEEP
CHICKENS OTHER
WATER SYSTEM: SOURCED B- BOTTLED S- SPRING W- WELL O-OTHER
'544+ Vr-J- CW- COMMUNITY WELL
WELL DEPTH (FT. ) TREATMENT TYPE
RESERVE DRAINFIELD AREA (Y/N) , )
PERMISSION FOR ACCESS TO INSPECT THE SEPTIC SYSTEM ( Y/N ) ),/
COMMENTS: f+rig e,unt CAT Z.J !/25r7 t) Foie /o.Q.7 AV-1 6 72 P
7ems5 g yE.4R. WATER ,ems FROM ouR /-162‘N,Oa P47 4,P lavn/ViG it +v4'LL. .
P S 7.425 :.s 7M P r.Ps r y ,h/A,.F A/F q,teO eP yta,P sc-i,PI/EXi v..ere y Ps4C
.Q ti Y D L4Y
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Totten Little Skookum Field Inspection
Action Sheet
Owner informed verbally of failure (y/n): Date:
Owner informed in writing of failure(y/n): Date:
Owner informed of need to meet with Environmental Health Date:
Copy inspection form sent to Environmental Health
(date):
Environmental Health ig - ff for having received inspection form:
Signature: Zcc ( ci-a _ Date: S' 26 ,,r
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