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.. - <br /> F V L R F T r" �1 HEALTH DISTRICT <br /> EN6'IRONMENTAL HEALTH DIVISION <br /> Courf House, Evcretf, Washington 98201 <br /> APPLICATION FOR A SEWAGE DISPOSAL SYSTEM PERMIT <br /> (Submit 3 Copies) <br /> 1'c�mit to bc issucd to: . ... . . . . _.� Ol .<t!_ ._./._.:3-!<!1 q . ... ... ......__. ._ .......__. __. ___. . ._.._ .. . <br /> Por installation at: (strcct address). .S—�`� S.� .a�+..�:. ..2.�...__.!�L '..._.. �_ � ' - ' ' <br /> .. .. . ... :�. - <br /> _ . . ..`. r.: f �:.-� � :. <br /> Addition or Subdicision ... .l. ✓C.; ^! _. ._i�r�c:a.'_5...._ . . l �1 t,�, r •� _. _ . .... Lot .. � . . I)lock . <br /> i � <br /> 7'qpc of 13uilding: Ncw v' . Sxisting__ . . Singlc family residcncc .✓� . . _ NumUcr of bedrooms.. _.__`/:.._._.._. <br /> Ot6cr. (specify typc or usc)__._. _._.. .. . .._.. _. _ _. ... . ___ . ._...._ ......__.. .__.. _. _ ..__..._............. ... <br /> ]3uildcr._... .�.. ' :-.'✓__. . �.L.S:/��.-•:t. ........__.....Address_f_3�k _...5__..lf�./�L<_...... . , �.f.- ... -.',:�. <br /> DrsiGncr_ .. .G.l:'�<.,.�_...__..�i�!�7.1.i..N......_._._ __.. Address._�� � iJ...__�'i "� �� <br /> /, ...3.�..... ....__. ........_�.......f�......_. . <br /> Soil Lo� Holc IQo. i_�.-•,..BL.:t,c..f._..FL,...:�.u .a_ . _.G.�..-..-��...�..�Y.,t..�w.�_L:?r3_^�......,.�6..�._.. �'' . . <br /> ,,, ;A•_ ...;:.�,.._.�._...r-�'..-...�::_�::..../.r..�.,.J��.,.�. ___. __........__..................._............ <br /> .................. _ <br /> Soil Log Holc No. 2.__... . .._�.:i....•-...�?........_. ..._ <br /> _ _... _ _.___...__......._......... _................................._......_. . <br /> . .._ _......... . _. ..._.... ..._ ... __ .____..___. ... __ . . _ _. _._.... .___.._...__ . ... .._.. . ......._ _. . <br /> L•'le��ation of �1'aier 7'able, i( encountercd. (DiaWnce from ground surface)._.. .N...�..�. �............_............_._.. <br /> Corrcctions to control snrfacc �ratcr i! necdcd_. . _ _ . _........_... .______....__.................._......---.........._. <br /> __._. . .. .___._ .....____._. .. _ ...._..._.. _ _ ......... ....... .. . .. ..... .. ... ........ . ..................__ . . <br /> Spcci(�- i( anp rcmo��ing or ��ading ot topsoii in firid arca..... ..............................................._--............................ .. <br /> . . _....__.... . . ._.._. __ __..__.. ._.___.. ......__._.... . .. ....._. .._. _._. .__.....__. . _.._.__.__.. . <br /> Pcrcolation: <br /> 'I'cst Hole iVo. 1 —Acerage Kate .�__ (Pall m minutes/inch-bottom G" test hole). Depth o( holr -<M <br /> Test Ilole A'o. 2—A��crage Itate_.`7�:._ (Pall in minutes/iuch-Uottom 6" test hole). 1)epth o( hnlc :=�'� � <br /> 7'est llole No. 3—A��crage Itale_ 9_ ..(Pall in minutes/inch-boltom 6" tesl holr,). 1)epth of hn;r �'� <br /> A����raGr, prrcolation ratc on �vl�ich to basc drain ficld design _....7"". • ^ .... Datr, takcn�' 7 } r' . <br /> . . __ _ . ....__._. _ .. <br /> Septic tank requirements based on present rules and regulations: <br /> 3 � ;� -_ .. .,, -,,, <br /> Scptic Tank Sizc_.�L�.F'�_�j ..._.._.gallons. / <br /> Amount of Squarc Pcct of Disposa] Picld.... . 5 ...H...�.........._�1�L/7; ���`' <br /> i <br /> Sicnaturc — Designcr__� �"•�....., �/. � ��'�r+ �t.. . . . _ . . Datc�� � � . . � : <br /> _ . . . ._ ___/� .._. .... _ . . _� . . <br /> ll0 N07' �17ZI7'li IIliLOW '1'IIIS LIIJE (1'o be completed Uy Issuing Agency) -- _ — <br /> Pcrmit issucd (datc)__.. . . ._ . ... ._ ......_.. . . _ __.....PcrniitNumUcr ._._..._ . .. .._._....... .. . <br /> R���narks:. . __ . .___ ._. . .... .... . . . . ....._ ... ..__ .. _ . _.. . . ._. .._.......... .... . ._ . . . .. . . <br /> . . ... . . .. .. . .._._... <br />