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' . . .. ._ _ .�Y., ♦ . <br /> � _ . . i . . . .. � <br /> SNOHOMISH HEALTH DISTRICT <br /> ENVIRONMENTAL H€ALTH DIVISION <br /> CourT House, EvereM, Wa�hingfon 98201 <br /> APPLICATION FOR A SEWAGE DISPOSAL SYSTEM PERMIT <br /> (Submit 3 Copies) <br /> . . /' I —r . / <br /> Permit to be usued to:.l�.<'-r..�.........!..12R?.n.�_� Cy,>`;.�r<..�'._T!��:2.......G�.•............................................ <br /> .......... <br /> For installadon at: (sueet address)....�G��.—�.....�Q%:-c.��.�._.._...�f:�.../�C�rcrC............................... <br /> Addition or Subdivision. .r��.iC�✓..f.:.. ..�.f..l�...l.��...�—�.........._ ..N...7.i'�/v{- S' /"S Lot..r.'....... Block....... <br /> � � - . .. . .. . ............. /.. .... <br /> Type of Building: New...�.... Existing............ Single family residenca..�....... Number of bedrooms.....-�......._.... <br /> Other: (specify type or use)..............................................••-----..............................--�--�-��-�--••--�-��-----............................................ <br /> Builder.�..N...r.i./.�....T/�d�<s.....G�n.;3�--.G..t[.:----.......Address...<a 75�:"a--._Evt.-.cyr.r.cn._!�[/„�r.... ./..-.✓�.r�h <br /> Designer.�.i!±.ea.*.�r.2�....C.�!l�rr....t�L�/m�........Address.r�[?../..l7......S..�rrn.e...l�!s•�..../.�.......�t.n.t`/� <br /> ry •• i• <br /> Soil Log Hole No. 1...4�-.:.�......To�....,..S.fl.<..�..........�..-.3..G.........Y.l��l3.r.��.................................... <br /> .......................................................................................................................................................................................................... <br /> Soil Log Ho]e No. 2.n-,��/..TGfl2......��!t..f..........._3./.—....3G..��.._/.i/�(B.t.�wxr�................................... <br /> ...........................................................................................................�-�--................_............-�--......--............................................. <br /> Elevation of Water Table, if encountered. (Distance from ground surface)...................................................................... <br /> Corrections to conuol surfacc water if needed...................�-�--•--................................................----......................................... <br /> .....................................................�-•-��-�---...---.................---..................................................................._.........................._................ <br /> Specify if any mmoving or grading oE topsoil in field azea......._......................................_.........._......._....----------............... <br /> .................�--.............................--�--.................................................---..............................................-�---............................................ <br /> Percolation: <br /> Test Hole Nu. 1—Average Rate.....�.... (Fall in minutes/inch-bottom 6" test hole). Depth of hole...,3�...F.... <br /> ,_ ,. <br /> Test hole No. 2—Average Rate.....7... (Fall in minutes/inch-bottom 6" test hole). Depth of hole...3�..�.... <br /> Test Hole No. 3—Average Rate...,.�.... (Fall in minutes/inch-bottom 6" test hole). Depth of hole....'3G � <br /> Average percolation rate on which to'base drain field design.....�.......-4................. Date taken._ .�-�.�L.��6.9 <br /> Septic tank requirements based on present rules and regulations: <br /> Septic Tank Size...._�.G2..0..............gallons. <br /> Amount of Square Feet of D' osa! Fic1d......3.,7..J:............................. <br /> Sifmature — Designe�. ...���..GlU..�.........-- .... .......... Date._.���Z:?.�(09.. - ... <br /> DO NOT 4V'RIT� BELOW T S LINE ('Co be completed by Issuing Agency) <br /> Permitissued (date)................................................................Pcrmit Number............. ................................. <br /> Remarks:................... ................................................................................................................................ ................................ <br /> �-�--��-�.....................................................�--�--..........................................................................................--......................................... <br /> Ken aeaao <br />