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REQUEST FOR A HEALTH DISTRICT PRELIMINARY CONSTRUCTION CLEARANCE REVIEW <br />Property Tax Account Number 3 <br />Owners Name: C"P6 V V- � CO-,-1 p ri P 7T-s � C <br />Mail Address: <br />j=J--- <br />Contact Person: <br />Mail Address: T DIq o ) <br />SITE ADDRESS: 5 ,1-0 c2-fiyi C/P S f <br />SITE LEGAL DESCRIPTION AND LOT #: <br />_ Phone: <br />City: 1/ <br />Phone: <br />City: <br />CIT <br />SP #/Plat name <br />Is Septic System/Drainfield: C INSTALLED/EXISTING* ❑ PROPOSED ❑ NOT APPLICABLE <br />*If installed/existing, approximate year of installation <br />Has a new onsite sewage disposal system application been made to the Snohomish Health District in conjunction with this proposed <br />building project? ❑ Yes A No <br />Indicate source of water: ❑ INDIVIDUAL WATER SUPPLY PUBLIC,WATER SYSTEM <br />y. A <br />� <br />Explain building project and its use (SFR, addition, shed, etc.): LL,,.riQ .,�,,., r <br />Is plumbing for any structures: ❑ EXISTING ❑ PROPOSED ❑ BOTH EXISTING/PROPOSED <br />Indicate total number of bedrooms before and after construction: / <br />ATTACH A COPY OF PLOT PLAN - 8 1/2" x I I" minimum showing: <br />1. Dimensions of Property Lines 4. Location of Septic Tank and Drainfield, if known <br />2. Dimensions of Existing Structures and 5. Roads, Easements, Driveways, Parking and Pavement Areas <br />their distances from Lot Lines 6. Location of Water Well <br />3. Dimensions & Description of Proposed Construction 7. North Arrow <br />Clearance review fee will be charged at the time project building permit is issued <br />You have requested the Snohomish Health District (SHD) to perform a preliminary review based upon the <br />information you have submitted to SHD as of the date of review. Any notice of preliminary approval hereby does <br />not constitute a vested right, guarantee, or warranty of subsequent construction clearance approval if in fact you <br />proceed by fling application for a building permit with the City or County Building Permit Authority, and SHD is <br />thereafter requested to ev ate he project at tha time/� <br />Signature of Applicant +—s <br />Date <br />FOR HEA DISTRICT USE ONLY <br />PRELIMINARY BUILDING CLEARANCE: <br />APPROVED: <br />❑ CONDITIONAL APPROVAL: <br />❑ DISAPPROVED: <br />REVIEWING SANITARIAN _ --,— �--2 /" <br />" DATE: <br />� 1 , <br />Rev041108s <br />4 Sld®I-IOMISH <br />HEALTH <br />DISTRICT <br />ENVIRONMENTAL HEALTH DIVISION <br />Water & Wastewater Section <br />3020 Rucker Avenue, Suite 104 <br />Everett, WA 98201-3900 <br />425.339.5250 <br />®9a7aE a EA rUULic HE�,aE L �9 <br />Hri H <br />ALWAYS WORKING FOR A SAFER AND <br />HEALTHIER COMMUNITY <br />I <br />