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, rt . . � � � . <br /> , . � e <br /> /t�;^.`1 SNOH01.115H HEALTH OISTRICT <br /> �■� VJaterNJas�ewater Seclmn <br /> � 3020 RucY.cr Avenuc++104 � �_ � . — �, �__ _ <br /> Everett l^JA 98201•3�00 Propeny Tax Accounl Number <br /> 425.339.5250 <br /> ❑ Ne�v ❑ Renewal ❑ Redesyn <br /> APPLICATION FOR AN ONSITE SEWAGE DISPOSAL SVSTEIJI PERtdIT � Repa�r ❑ Aneradon ❑ Rev�son <br /> Applicant_ ) . �_. �.• �si r, i a � . i . . / Phonez�i� -�(� �O�j <br /> IJading Address � ' /i !� C�ty �/ • •, . Z�p , - ,• � . <br /> For mstallation al� • / � . ���Y ` <br /> Sec_P,.P__R9—��4 Sec Subdrvis�on Name (or attach Iegal)__ Lol_I316_ <br /> �:'aler Supply. ❑Individual�vell' ❑ Public(more than one wnnecl�o�� Nam� __ __ <br /> 'VJe�I,Ae bcated grea'er Ihan 1,OOC L' Irom landl�ll property bcundary�. ❑V[S ❑NO <br /> S€WkGE DISPOSAL SYSTEtv1 DESIGN INFOR��9ATION <br /> Aftach 4 r.opies o/ tbe onsite sewage �disposalfplari- �vith�a min�mum ol �5 soil7og descriptions. - ' � <br /> Typeotpuddmg tde.v❑ Exi;ting� SFF❑ Du�;ler❑ tlolpedraom� � Comme�cial _Other_ <br /> SYSTEM TYPE(S)� Gravily�] LPD❑ Altema�rve Q (Type )Reduced System❑ Lot s¢e �� <br /> Depth to Water Table%Restrichve Layer. � mches. Slope m DramGeld!Reserve � ��� � � <br /> So�i TerWre Type(1-6) Apphcation Fate� _ gaVsq IUtlay Dady Flow Rate yalions�day <br /> Abscrpton Ama� sq N. Trencn Depth� inches 7rench Widih� mches Dale Soils Logged. <br /> SepPc Tank S2e� gal. Pump Chamber Size: " — 9al Pump gt�m'Head � <br /> Requlred Sandy Loam Cover SoJ: Depih i � inchesNo!ume . cub�c yards <br /> �. . � : c . � . - . <br /> S�gna�ure ol Des�gner� __ -- <br /> Deslgner�s Name ' Cehdlcaled Phone ��lo. _ ___ __�_� ._ . <br /> Address i. , i ' Cdy . •. . .�_Z�p Dale . i , <br /> ---- —�--- -- .'. <br /> FOR HEALTH DISTRICT USE ONLY �' <br /> ; i <br /> APPLICATION APPROVED__� Sani!arian ~ _" ^ ..—_--- Dale�_/_�_ /� _ _ <br /> Comn��n�S�COnddion5 "See reversc side and enclosed memo(s) tor additional inlormation <br /> .. --- . : , � . . . , . J y - - --. _ . <br /> . <br /> APPLICATION APPROVAL EXPi^nES UN: <br /> Appruval ol Ihrs ;pphr.alion is based solely on infoima�ion prowded in Ihis application and docs , _ <br /> nol conshtute a Pem��d lo beg�n construction ol Ihe �ystem or any other improvementc on Ihe <br /> sde. Th�s approvai shall NOl be considered an assurance, caher expressed or implied, Uiat <br /> developmenl permils lor Ihis sde �vill 6e Issued. . <br /> APPLICATION DISAPPROVED: Sanitanan� � Date�_ . _ <br /> �Seedeniailetler) � / / <br /> P[R�.LT ISSUANCE APPROVED/by. � Dale. � � ' <br /> PERMIT NUME�ER: ��'���'�� Installer. <br /> Final Inspecuon request by: Da1e: <br /> Rnal Inspeclion approved by. Dale: <br /> i u>.,a «, i i i,oz, ��� <br />