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�� �, SNOHOMISH <br /> ��� ,HGA�TH DISTP.ICT Application For An Onsite Sewage System Permit <br /> �-�ww ;r�o�10 oWc Supplementa! Information Report <br /> Appl�cant Name�/ �7'on _— <br /> �7 �- <br /> Tax Account #_ i/3�/�OGO G6 ZLtI Property Location _f[/%l � �� �� ����� <br /> ReviewingSanitanan _.�rGt(e Ytc o�1s,(� _ Date _��__/,L� <br /> The follo�ving checked boxes indicate mfcrmation concemmg your approved onsile sewage disposal <br /> system application and design. Additional information can be found on the back of your approved <br /> app6cation (orm. <br /> (�._Prior lo permil issuance a pre-construclion conference betv✓een designer/engineer, certdied �n;taller <br /> and Ihe Snohomish Health District (SHD) �.vdl be held at v✓hich lime agreement �:�ill be made <br /> �oncerning: <br /> 1 Adherence to construdion plan details. <br /> 2 Supervision by designer/engineer on sile. <br /> 3. Pressure ieshng of the distnbWion system with all holes up and unobstruded (ivhen appl�cableL <br /> 4_ Adherence to design; allowing changes to be madc only �v�th �mor �vniten suhrnittal to. and <br /> approval by, SHD. <br /> ; The foliowing shall be provided to the SHD prior to issuancc of onsito scc:aye dis��osal system <br /> installalion permiC <br /> ❑ A conformed copy of the recorded operation and mainlenance Declaration oi Covenanl (copy <br /> enclosed). <br /> ❑ A copy of a signed operation and maintenance service agreement with an approved serv�ce <br /> provider(s). <br /> ❑ Payment of an Onsite Sewage Dispersal System Permit fee <br /> ❑ fhe designer/engineer is responsible for veii(ying sand fdl quahty al thc �ob site <br /> The following information applies to all onsite sewage disposal system inslallations <br /> • This approval is limiled to a SHD delermination as to corr��hance with SHD and Washington <br /> Slale regulations applicable to onsile systems. SHD makes no representalionsldeterminations <br /> as to full compliance with other land useldisWrbance regulalions mduding, but nol limited to the <br /> Indian Graves �nd Records Act (Chapter 27A4 RCW), the �rcheological Resources Prote�:l�nn <br /> ncl (Cliapter 27 53 RCW), or the necessiry for compliance with any olher regulalory entity'� <br /> rogu!ahons relative �hereto. <br /> • /1 SHD sewage disposal inslaila�ion permd �vill not be issued before lhe city/counly building <br /> permil. <br /> • Permit issuance will be timed to coincide with a mutuaily agreeahle construction date and muy <br /> be subjed to dry wcather and dry soil installa�ion. <br /> • Both lhe seplic tank and pump chamber shall be conslructed and installed in such a rnanner <br /> Ihat precludes the intrusion ot ground water • <br /> • The designerlengineer agrees to provide operation and maintenance in(ormation includu�g an <br /> "as-builY' construclion detail to the owner and to the SHD. <br /> Questions regarding this report should be directed to the reviewing Sanitarian at 425.339.5250. <br /> HD�77 �e�Cn 31�..l:s <br /> Environmental Health Division <br /> 3020 Ruc4:er Avenue, Suite 104 � t vereft vJA 9E:01-?900 � iax� �::5.339.5754 � 121: 425 337.5250 <br /> � �3t <br /> �',� <br />