HomeMy WebLinkAboutSWG Application - 6/21/1974 4;'.1 1Z.O. Box 746 No. / ',4r
Shelton, WA. 98584 THURSTON-MASON HEALTH DISTRICT 4th & Brenner
Phone: 426-4407 DIVISION OF ENVIRONMENTAL HEALTH Olympia,WA. 98501
Phone: 753-8073
OWNER t hei C. ic B G toV LA s PHONE,! 2 /3
OWNER' S ADDRESS Z p . _ b CITY la n , p y' STATE yin
SEND REPORT TO Er, , 0 72. CITY U h , u i, STATE VIA ,
SEWAGE CONTRACTORWs•r L a__✓ ct., a k A f ADDRESS A 1 \ L ,.l y16
(If self confer with E.H.S..) '�I 7
LEGAL DESCRIPTIO A. .c.�� f 0D D i* LI o1- 2, +L inL' / L. . 3q 2 2 3
PARCEL NO. LOT IZE 's b x t 3 Z U INTENDED USE OF BLDG. hi,,,, on u
NO. OF BEDROOMS Z NO. OF BATHROOMS .2.• BASEMENT PLUMBING: Yes No- _
NAME OF WATER SYSTEM -he t ti d•t.t., YY I J INDIVIDUAAL pe PUBLIC_COMMUNITTY
DIRECTIONS TO PROPERTY: (Be Specific) Cyt 0,, i „.- •r,- f..S i je0 AA A id c iebie4D
DRAW A SKETCH SHOWING: 1. Property lines, location of house on the lot, and dimensions of the
lot. 2. Location of the house and sewage disposal system in relation to streams, lakes, wells,
soil log holes, atio, driveways, underground tanks, water supply lines and easements.
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e septic system is an approved temporary method of sewage disposal
DO NOT WRITE IN THIS SPACE
MINIMUMS:
Septic Tank i�i foci j�lis,ue 44,,,e
Drainfield ;,/G /W'o/c/,,"1/' Plc/
SITE APPLICATION
/ / APPLICANT'S SIGNATURE DATE 7
i SITE INSPECTION FEE RECEIPT NO. BY
APPROVED NOT APPROVED BY
Date Date Inspector/E.H.S.
SEWAGE APPLICATION / / NEW / / ALTERATION
/ / APPLICANT'S SIGNATURE DATE
/ FEE RECEIPT NO. BY
PERMIT NO. APPROVE
,
Date Inspector/E.H.S.
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