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■ <br />��$� ��-` i-y�7�5.��'t�����+FS f�v�:�r'w. r., ' �� �' 'J / <br /> ���«�� w� p� �/VOMOM/SH NEAL TH D/�TR/CT <br /> �{4'y4' a,kz <br /> R1�4� �`�r`l� 4'"`�,�a 4� �,^`.` Courthouse,nEverett, Waehingt'on'o98201 <br /> � <br /> � '�`��� x����` ��;�. � 25&9473 <br /> ��� <br /> ��L��pTIQN FOR OR1-SITE SEWAGE �ISPc'J'SAL PERMIT , <br /> (Submit 3 copiesl � a . <br /> ::i''�, �,�o�SU�� .�i ' ���/ ' <br /> _' :� /,� Property Tax Acroun[ No. <br /> ''' �i�'6- Y t%/ /�tI L J� <br /> #�� �o bc issued to <br /> '`'`�� instullation at (strec[ address) � � � � S� t�/�/�� " <br /> For <br /> - 5��.�� Twp.�� Rg. ���__Le@al Description: S'E��S(.r/�ti�f�f AiiU�jCa � 7�.7-l�'S �.�:( �. %d/� ' <br /> Sliur[ Plat/5 Acre Srg. No. Nro/�C�J .��Lot_; Plat Lot Blk. <br /> � — — <br /> Type of L'uilding: New� Existin6._,Single famity residence k, No. bedrooms_� Other use �-' � <br /> Waler Supply: Name of public �✓�-'t/�� Source o( Private <br /> I3uilder i�IQS'Y"�� '"'f+L .'T Address �'7 �- Q 7 ��j � �]�i rs{7 Telephone_Z_St" ±'�Z'a " <br /> �-. (sveet/ lcip7 <br /> Designer �(�/'�s��/t j •i�.�•��f�'.Ca+'/-2,-;til��ddress_ .".?S�:<'_ ��'�! / %��fo � t..'�i/�=�'c:� Telephone �J'S' �_f%•."=• <br /> / /sviceU (i' lciny <br /> Altach a detoil drawing to scale of the on-sile system indicating: soil and perc. holes, drainfielJ lines, 100^� reserve area,elevations, <br /> bodies o� water, property lines, house Wca[ion, banks, excavations, easements, north, and any wclls within 100 teet. <br /> Soil Log Hole No. I _��T^ �T��"?;��� � - � �1.•X s'T G-�( " .�C. i i^�E ir �)_oi . <br /> � :T <br /> Soil Lug Hule No. '_ �• ,1 r�-AZ �.V � � �U,/Y' Y U - ✓--6 • <br /> � , ��� <br /> Elevation of Water 'I'able IUistance from ground surface� -� <br /> i'ill needed: IDepth & AmounU ----'" _ ` <br /> Percolation "fest: (Fall in min/inch-botrom 6" oC test hole) I <br /> 'icst Holc �o. I Average Rate Depth [est IaAen Test Ifule No. 3 Depth lest taken <br /> 'irst Ilule No. _' AveraFe Rate Dep[h [est taAen Test Hole No. d Ucptl: test taAen _ <br /> :�vrragc 1'ercolation Rate "'� Dace Taken r - --Y';�� <br /> -+.-� i Y;�' . <br /> Scpiic �fan�: Site ;'C'�=' c� gallans, Sq. It. i i � Tr. Nidth /. r "1'r. Drpth i v. <br /> Signature of Designer �,y:�... �._�_ License No. � '/�� D:i�c -`_r- /G�'1���' <br /> r <br /> DO NOT WRITE BELOW THIS LINE (to be completed by issuing ,nency) <br /> \Vell SetbaeA Complianee: Yes_No__Pcrmit Denied_ Sanitarian ___ <br /> Ycnding: Idatc) <br /> Permit to be issucd �5� Dale �� - `l� / Sanitarian `\�...�� , �..''��A....�.-� <br /> CalleJ for Inspeclion Installer Reinspection <br /> Permit issueJ (d�te) � "" Permil Vumber Permit Renewal _ <br /> Ho-�a ew: �ano/mk . . ` � �' �'.�'.% .._ _ � � <br /> ' / . ' —_ <br />