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_.� - <br /> �, ; � - SNU�. JM151i HEALTH D15iRiCT <br /> _ � <br /> t. /-- Environmental Health Divi�ion � <br /> � Courthouse, Everott, Washinpton 98201 <br /> � ��'PUCAT�01`� FG� A SE'vVaGc �iSFGS�1� SYSTEM PERMIT <br /> I Submit 3 copiesl � <br /> � Acct.\o. _ _ _ _ . <br /> Pcrmit to bc issucd to .. F.^-'o, '};- ]S 7�' �; ,"r . ,�� <br /> , � . ._ .. . <br /> For installation at (strect address) -� %':l - •�•�,•:.,, <br /> ' _ ' <br /> Sec.'' Tw•pr �=' Rg. '1 Short Plat No. Lot_Plat �--..' .- - :,' , ` <br /> I ...,.��,_Bik. <br /> + Typc of Building: Nea• � Existing Single family residence No. bcdrooms � <br /> Water Supply: Public t Prn�ate Other. (spccify typc or_ase) <br /> Buildcr •'� ' nddress "' • ��, � _ '-t ,.. - <br /> Telephone ' <br /> - ' i <br /> � Dcsi �ncr - ._ . , , -,;',�:':,� � - _ � .. . <br /> b address _.. Av:�. . . . :�e':' <br /> " icense No. ` <br /> Suil Log Holc No. 1 - ' ::,. :: _...._... ._i, : . . , . .... _. <br /> - �, ,.. _. _ , - - , .. <br /> � SuilLogHolcNo. 2 _. . .... .. . . ..... . ... : . i •_ - r.. , <br /> Elevatian of Watcr Table, if encountered. (Distance Gom ground surface) � <br /> Correc ' � .� <br /> Uo <br /> OS <br /> IO CO <br /> ntrol surface water if needed <br /> Fill needed: (Amount) � �^ <br /> Penolation: ' <br /> Test Hole No. 1 Accrage Fatc lFall in min/inch-bottom 6" tesl hole) Depih test taken <br /> Test Hole No. 2 Aceragc Rate (FaII in min/inch•botrom 6" test hoic) Depth tcst takcn " <br /> Test Hole No. 3 Arcrage Rate (Fall in min/inch-bottom 6" tcst holc) Depth test taken <br /> Average percolation rate on �chich to base drainfield design—` ' �ate taken � ' <br /> Septic tank rcyuirements based on pracnt rules and regulations: <br /> Septic Tank Sizc ' � � gallons. <br /> Amount of Squarc Fect u(Disposai Fcld '- Z-�, �y����� <br /> _Tr. Depth _ <br /> Signature of Designer ��� ' - `) !f,�' ; <br /> ... . . _... _'� . Datc �_ � . <br /> DO NO7' W RITE BELOIY 7'HIS LINE (to be completcd by issuing agency) <br /> No Pcrmit_Date Sanitarian Pcnding <br /> ' -. I <br /> Pcrmit to be issucd � n��� '� �� Sanitarian ` <br /> �Z«�'«��d Sanitarimi Wct 1Yintcr Months / <br /> Check Received Cash Received <br /> Pcrmit Renewal <br /> Callcd for Inspection Installer <br /> Permit issucd (datc) Pcrmi[ Numbcr <br /> t�•--- <br />