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.NOV-03-2009 TUE 12:00 M snohomish health dirt FAX NO. 4253395254 F. G4 <br />`rSNOHOUDISTRICT vi lj/ O hi <br />Waierh aotowater Soctlor. <br />/ oo <br />3020 Ruck9iAvenue z104 C� CF �yg � <br />Evcrott WA 9001.3900 property ax Account Numoer <br />d2S.339.5250 <br />❑ New ❑ Renewal n <br />APPLICATION FOR AN ONSITE SEWAGE DISPOSAL SYSTEM PERMIT ❑ Repair ❑ Alteration ❑ 9evisicD <br />Applicant_ < GCLr`/�/`( �� �OP Phone <br />'L[�iL c IVVWCre/mil jp <br />Malling Addrass �i C ( �/ City <br />For Installation at <br />Sec C' Twp Rg bj 1/4 Ste:--//),.1/_''''��SuhUlvisien Nnme (or attach local): r <br />Individual well* �A �� Lct__3d'_. <br />Water Supply: ❑ Publlc (more then one connection): Namo '� (/elp� n— <br />'Wellsite located gr4atarthan 1,000 ft. !ram Inndllll property boundary: []YES ❑ NO <br />SEWAGE DISPOSAL SYSTEM DESIGN INFORMATION <br />Attach A coples of rile onslte sewage disposal plan wltb a minimum of 5 soil log descriptions. <br />Type of 8ulldintl: NOWF ExlsungJ SFRG Duplex El s of Bodrooln �omma o Othar <br />SYSTEM TYPE(S): Grnvlty ❑ LPD [i Aitama ivo 0 (Type flL1J(tii� 'FAMy ) Reduced System[] L,t ziza Q. ''• <br />Dopin to Water Table/Rastriut o L.iyor:=� inchoe. Slope in DrainfialdrRaserve' �" '/ / —^I <br />%✓ �1� e o <br />Sell Texture Type (1-6): AppllcaGcn Rota: aysq )Iday. Daly Plow Rate: Y gallonscay. <br />Absorption Ama; sq.ft. Trench Dapth: Irtchas Tr ncn '" M: Inches Date Soils Logged: <br />Septic Tank Slzo: / 000 gal. 6JM 6 -'r -MChamber Size: �f g Pump grimrHoad <br />Required Sandy Loam Cover So�C: �Deoth>� 1chAblume euhic yards <br />Siqnature of Designer -;SST-Ir-, �� j�Q�� • - _ <br />— C <br />Designer's Name._ ��[',`rG�o '+' ✓C..'__.. Cenlficate$ l Phone No. <br />Addmas 0 - City r, r{ o. n t $ 7/ Zp �r �2>� Date ! £J! ✓ 'v <br />FOR HEATH. � �n 115E ONLY <br />f <br />APPLICATION APPROVED_,.• Sanitari:r J nDaleti._ <br />Comments/Conditions: **See reverse side and enclosed memo(s) for additional inbrmstlon <br />APPLICATION APPROVAL. EXPIRES ON: <br />Da..e:Di%io tlfw <br />Approval of this a plicatlon Is based sofa y on Inlnrmatlon provided in tnia application and does C1 rk: 323 rivoi cell ZC115S1:- <br />not conatitute a f�ormit to hapin construction of Ilia system or any other improvements on tha Su t>i( mamiSfl 400.00 <br />sits, This approval shall NOT be considered an assurance, either expresnad or implied, that development permits for tom site will be Issuad. HealwAstict 400.00 <br />APPLICATION DISAPPROVED: <br />PERMIT ISSUANCEAPPHOVED,by: ei r.i Date <br />PERMIT NUMBER. 3y%S,V Insta <br />Flnallnseoctionrnquestby: Ct"t Dow <br />Final Inspuctlon approved by: ---��' <br />Date:_ 11 10 _ I <br />k Fa.l <br />IiD•)a revII1302) r <br />eel:er-1040 400.t:0 <br />Che. oc,,: 0,.•CI <br />' 400.U0 <br />