HomeMy WebLinkAboutSWG94-00989 - SWG Application - 8/4/1994 ,c'�as��+.r;:, w. . ;.,, -:. P RMIT;NO: SWG.S • _ 9I MASON COUNTI >•EP.,1TMENT OF HEALTH SERVICES
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4.261 W. CEDAR/P.O. BOX 1666/SHELTON,WA 98584 ' y o
.- PHONE (206) 427-9670 { Amouint$o. #14 )(� Z
PROPER WNER: DA I E: co
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1 )<"\I‘Ck C . R l e ' CHECK APPLICABLE ITEMS s S
MAILINGADDRESS: • INSTALLING NEW SYSTEM 0.
\ DAYTIME PNQN {
i •j• \•tC>', �•4, )-\`-.(, 'N` t REPAIRING OLD SYSTEM CO
`CITY STATE: ZIP: EXPANDING SYSTEM
nl l SINGLE FAMILY R
PROPERTY ADDRESS: 1, �� OTHER o / 537
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..._ t'A \( -SN'_ SPECIFY:
PRIVATE WELL 3
SPECIFIC DIRE TIONS FOR•.�OCATING SITE: m
C-c, rr\1\ n c , .1. \ Ct�-i\ t�lr�. "Sic PUBLIC SYSTEM - `\.)c' ft
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\: ;1, h • �-.c•\ • �' SYSTEM NAME /,
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` 1 ) APP CANT • C
1 :Name of'
JNAME \ C . o).,,s_Lot ft.x ft MAItLING`AD,_DRESS\"} O , , , '
Installer >,: 'Shct Re'n I ,Jl-� t A I`.�
Size.."' .� acres TELEPHONE. (`. '' ) ��G r��13 q
Name of Number of SIGNA UR y:
: Designer \ r- \Q �r. F
�� Bedrooms �� „j /�/? X `. ` \�` {� CI \ „v,� S
..PLOT PLAN j ( --S C'`r 4" 3 U \ I L
Draw a dimensional plot plan, •
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including:
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O Precise location of test F' ,\!N �� ��,� \ , V C��
holes,showing IC
measured distances to
property boundaries.,-•.,r ,' ,_ i ._.: :r ".• . \ c . .k, y. • r ..
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'CI Entry Toad;other roads, ;, { - o I
driveways.
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NOTE: vDO NOT DRAW IN ^�� _ ` N
SYSTEM DESIGN ,•*1-c irs.. lz' - - '•"
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OFFICIAL USE ONLY. DO NOT WRITE BELOW DOUBLE LINE. . '
, T� • TN tf to SOIL LOGS
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" !d-vtaRNu�GQRvFc , 6-25- SHnOLGA��n .
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•r ,.. " .. Depth from Original
- Grade to Restrictive
._ - .. - -- __, -. _- w.-- My- Layer or Water Table: /0 In.
DESIGNER DESIGNATION SCORES MINIMUM SYSTEM REQUIREMENTS
Finding Score I Designer Level: 0 One ,ef Two
Soil Type - LI . 2
Vertical Separation v In. 1 S Septic Tank Daily
-- ‘ Capacity: 36 Gal. Fi9vv) y. 0.Y)-/.4.) GPD
Slope " - 79 %. .1St ,,
Appl... Infilt. -- .• ' .T, '
Parcel Size -NI '&7 s Ac. S Rate • (o GPD/FTP Area 2'-/ , FT7
Distance to Shoreline (19 ft. Total /a Inspector Date
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' COMMENTS/CONDITIONS ONDITIONS FORAPPROVALr-AkTs'c = ii o�tc II tv t 6.41
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Any change from the specified use of the property or any site alteration affecting the System design may Invalidate this permit.
This Permit expires 3 years from date of site Inspection.Denial of this permit may be appealed to the Health Officer within 10 days of denial date.SITE:A
AWoved ?Design Required O Not Approved DESIGN: Approved L Not Approved • INSTALLATION:O Approved CI Not Approved
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BY: .k- DATE:S-/c..2., BY: // / i . DATE:: /6%c% BY: DATE:
7\"... ,slp _ TOP: Health Dept.;Co ; MIDDLE'Designers Copy BOTTOM Applicant's Cop i
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