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�'� '\�, ( /zESu i3Nt � �TA L ( ��� s ��N) �--. <br /> � NOFiOMISH HEAL� H DISTRICT � <br /> � Environmental Health Division ��� � <br /> CaUfthoUse, Evefett, WA 98201 • Phone: 259•9473 , (pNOPERTY TAX AC NT NUMBERI <br /> APPLICATION FOR AN ONSITE SEWAGE DISPOSAL PER IT ' • - <br /> (Submit 3 CoD�etl � � <br /> Applicant f��l=OLI� �f iVE1L Phane H= 2S2^5695 <br /> Addreu ;008' LKES� L,A.UE EVFRET WA. 9ff103 <br /> For installation at /1ZEST LAAlF FVEItE7T L✓A 9£f�0� <br /> $et.�{� TwP� A9. H Legal desc. <br /> Shon Plat/5 Ac. Seg. Na. Lat ; Plat Lot Blk. <br /> Typ� ot Building: New ✓ Existing SFp � Ouplez No. Bdrms,�_ Other <br /> W�ter Supply: Fu61ic ✓ Name EVEIZE iT Gf T y Ltr, o( Availahility <br /> Private Source_ Pratectiva Covenants <br /> Attach o detail drawinq to scale a} tha oasite rystem indicatiny: soil log holes, drainfield linas, 100% reserva area, contnurr, elevetions, badies of <br /> w�nr, property lines, hause lacatian, 6enks, ezcavations, easemenn, narth, end any well within 100 teet. <br /> SOIL LOG 1. O—/6�� 'saw/�T Loaa,�. lff'� �f�f+�e� Sn,.� <br /> SOIL LOG 2. (I- /2~ � lT Lx.wy /�^20�� Gonwv Sah 10��50���- S.�( <br /> SOIL LOG 3. /�-/n'� aGa.� �o"- N��f Swwd <br /> SOIL LOG 4. 0�13�� ��.��o, a�. �/3�% 3��� S� 'f'r� e .�2�� <br /> SCS CLASSIFICATION Loaw.� Sn�rc� SOII TYPE 3 ApPLICATION flATE�..,� gal/sq. (t./day <br /> DEPTH TO HIGNEST SEASONAL GHOUNOWATEH �_ins. OBSEflVEO ESTIMATEO�_ DATE 9 / 2'! I Y6 <br /> COVER SOIL flEQ'0. (depth end amount) l���'�F <br /> SEPTIC TANK SIZ 00 _ gallans TflENCH: SQ. FT. sr�a.. WIUTH .Z�} ins. OEPTH 2� ins. <br /> Siqnature af Designer � /o� f,i���/l Date �� / ZC�I ,��v <br /> License No. � � � �-?i 7� Phone 7�-� � SSd 0 <br /> DO NOT WRITE BELOW THIS LINE <br /> Permit Oenied Date I I Sanitarian <br /> Well Setbeck Compliance: Yes No � - <br /> Wndinq: (date) <br /> qPPROVED �� Date O 27 � �6 SANITAflIAN �vL.� <br /> PERMIT ISSUED: (datel �O l,�Cll ��O BY� PERMIT N0. � `J��oz��� <br /> CALLED FOfl INSPECTION: (date) / / 8Y INSTP.LLER <br /> A copy of the Neclth OistricYs Appeal Procedure will he furnished upon requesa "���� <br />