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c � ro <br /> ro <br /> � a <br /> � " y � i � <br /> ,"�� � � SNCSF;OMISH HEP,LTH DISTRICT ' ' <br /> o m o Env�ronmentzl Hoal;h Division , <br /> y y H CoarlM�se, Eve�etl,WA 9F201 ' ��- <br /> 33P�52)0 (Proper,y Tas Accouni Numbe,) <br /> � ¢ �� � � AFFLICATION FOR AN ONSITE SEWAGE DISPOSAL PrRMIT :pt�ew ❑Fienewa� ❑Rednsian <br /> M � ❑Repair ❑Allaretion ❑AHemative <br /> G1 • . <br /> ~ r� � �FOGcant Phone-"-"-'�=`•� -- <br /> � y tdailinq atldress � - City �'� Z�P — <br /> � N r. For installation at "�'�� ���y �� � � � <br /> O N . '„•.�.� _ �,. <br /> � � r Sea <-� Twp. � Rg. Legal desaiption <br /> '� � Shon PIaVLLS No. �� Lot -' : Plat Lot_ Blk. <br /> y , <br /> Type of Building: New_ _ Ezisting_ SPR_ Duple�_ No. Bdrms.[ Commercial_Other <br /> 1'later Supply: Public�-_ Neme ���' � � � r ��'��� ' (Attach Lei2er o1 Availability) <br /> Private__ S�urce Protective Covenants — <br /> Atlech • dcleiled drewing lo ■�ele ol the onsile �yatam Indicaling: �oil lop holes, dr�inlleld Iina�, 10Uh <br /> reaerve •rea, conloura, •Ievetions, bodies of weter, propstty Ilnea, hou�e locetlon, b�nk�, •xcevelions, <br /> eeeemenls, no�lh, •nd �ny proDo�ed or •zlsting well within 100 1oal. <br /> SOIL LOG L �''�`��� ' <br /> SOIL LOG 2. ���"��� �`� <br /> /,.. <br /> � SOIL LOG 3. ��-`0" 1` _ <br /> C�, ._,. ,, .,, <br /> 1 � SOIL LOG 4.__ �)-�i.�" Ciir. �� •'- �.r•C: <. . •. •- • �• <br /> � <br /> ��� — <br /> SOIL LOG 5. ��"�'��� I�� ' <br /> SGS CLASSIFICATION - - SOIL TYPE APPLICATION RATE P aalJsq. riJday <br /> � � �:�,�' ` <br /> � <br /> DEPTH TO HIGHEST SEASONAL GROUNDWATER '_Inches OBSE(iVED_ESTIMATED>' DATE �� / = r�� <br /> SEPTIC TANK SIZE -' aallons TFENCH: SO. FT. ��'-�' WIDTH �'4 Inchea DEPTH_ =< inches <br /> �w' � , REOUIRED COVER SOIL: DEPTH 0 incfies,and VOLUME �� abic yardc <br /> � .� <br /> `•` 1 - -�� ^( - ",`'! <br /> o � '% � j <br /> Si�nature ol Designer �' �� � � License No -� ' Phone No. / <br /> J ' � <br /> ' � Address •c.>' � - — �— City ;� �l ' .�.•_ Zlp� _ � Date . �-1 -� <br /> a� — <br /> � DO NOT WRITE BELOW THIS LINE , <br /> I � <br /> � Application Denied Date I � Sanitarian �� <br /> � � ... . -� �. .. , . : • '� -- . � ''��. �. . „. . � . : � .� � <br /> �� <br /> - �Pending: (Date) " 1 <br /> � � ^� ' <br /> � � . . . . . � . � _ . <br /> 1 t l <br /> APPLICATION APPROVED Dale � i i � SANITARIAN <br /> � PERMIT ISSUANCE APPROV[D Dale__/ I SANITARIAN <br /> � PERI.'IT ISSUED: (Datn? / � BV PERMIT N0. <br /> Wiled For Inspection� (Date) I / __dy Inslaller <br /> � Rnnewal By Date � r Final Inspection By Date i ' <br /> Hn �• <br /> ' Se•P �evcrse swe tor ,amt�ona' inlorr�,a�,ia�� <br />