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�iQ90HQMtSf-1 6iEALTt� P�QSTRICY .. <br /> Environmentnl Henith Diviaion . <br /> Courthouae. Everatt, Waahington 96201 <br /> APPLICATION FOR A SEWAGE DISPOSAL SYSTEM PERMIT <br /> [Submit 3 copiesl � <br /> , Acct.No. 3/�'S -DOO� Oz3-ozaS <br /> Pcrmil ro bc issued to ��� . �-�SG ' � <br /> For installatiun at (street address) ���7 ���E� ���6� ��• <br /> / v � <br /> �eVGr�y �rO�•G � r '•� .Z. Lot�Blk. <br /> Scc.�Ll'��'p,�Kg.¢Sl�ort Plat No._L.ot_Plat � <br /> Type o(6uilding: Nca '� Existirg— Singlc family residcncc <br /> � No. bcdrooms <br /> Water Supply: Public `LX��'��„� Frivate � Other. (specify type or use) <br /> �� S C:oti/5 r Telephane � `�3� �'3� <br /> Builder Address <br /> �� � / / /� 3 7�� <br /> fjfcJ�//�/-� Addres:��� NE ����//"��3 I-icense No. <br /> Designcr _ . / . �� <br /> n ..��v Lna 9G- 47 e�� a.,.� /04 nr � <br /> 4��0 %�,.�,:/� .S� n. n�•.- ruN,,. <br /> Soil Log Holc No. 1 � �voJ� :• 5�-7-53'�r•�•,`c �� s, /r�, S..r,dy /�u -• �? �,- <br /> c/u y ' / _s,..� - g �„ <br /> . ' _,n S��/ 2-3G�" Loo•�- Sa� <br /> ?Io— /r Gc..i. ° <br /> Soil Log Holc No. 2 ' � �� u ,.,� p /1��. ��,., b�yn�d 54 " , . <br /> �.�.�c/% s� � ��'�-5 <br /> �---- <br /> Elevation of Water Table, if encounlered. (Distance from ground sur(ace) <br /> Correcti.nns to control�surface w•ater if needed_ � <br /> �----- <br /> Fill necdcd: (AmounU . <br /> Pcrcolation: � � <br /> . Tcst Holc No. 1 Averagc Rate � 5 (Fall in min/inch-botrom 6" test hole) Depth tcst taken <br /> ' Tat Holc No. 2 A��erage Ratc_O.-' (Fall in min/inch-bottom 6" te,t hole) Depth tcst taken —Z 7 <br /> Test Holc No.�Average Rate �—(F��� �r, min/inch-bottom 6" test holc) Dcpth tes[ takcn , ', /' L ,—�— <br /> � .C� iSatc takcn <br /> Average percol�ion ra�e on w�hich�io base drainfield design , i <br /> $eptic tank requirements Uased on present rules and regulations: <br /> ���� oallons. Z CV� �• �{ � <br /> . Scplic 1'ank Sire r �r . . <br /> 4' r. 3 Z� Z��15'9�. Z 1 Tr. Depth Z`T <br /> Amount of Square Feet of>Uispo al �eld � k� • <br /> �i :�-iiC<u ;/l���G -_�at>. // � 7 7� <br /> Signaturc of Dcsi�ncr - • <br /> DO NOl' ��'������- �;�LON' THIS LINti (to be complcted Uy issuing agenc�9 <br /> N� p�����i� �_Datc Sanitarian Pending � <br /> Pcrmit to bc issucd Datc Sanilarian <br /> Rcchccked Slnilarian �Vct Wintcr Dlonlh5 <br /> Cash Recciecd Pcrmil Reneµ•al — <br /> Chcck Rcccivcd . <br /> Called I'or hispcction ----Inslallcr � . <br /> / - �-� Perniit Numbcr �S QC ` � � <br /> Pcrmi[ issucd (datcl.�/�-� , <br /> r a---�- <br />