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� <br />SNOHOMISH HEALTH D«TRICT 4'Zz'4' <br />Environmentel Hesith Dlvislon <br />Courthouf�� Everett, Ws�hinpton 98201 <br />APPLICATION FOR A 5E1NAGE DISPOS�'�L SYSTEM PERMIT <br />f Submit 3 ropiesl <br />l/e�� <br />Pcrmit to bc issued to ��� �� G µ��'��'� r -- <br />,' i e.;. -7 �. ...:..� � �Y- ;f!• <br />For installation al (svicet address) � � t �CLV�bE2� ry!'�.VE � �VE2E77 �/1 <br />Sec.�T��•p.J� Rg.�Short Plat No. Lot_Plat Rtp��T LL+T K DA2uNEi�� Lot� Blk. <br />Tcpe oP Building: New x Existing Single family residence_�_. No. bedrooms ✓� <br />\vater Supply: Public G�� ���tTr Private Othcr. (specify tppe or use) <br />�i�����«� GI+ILELL� Address <br />��`}30 /'-� PL•C�i �Jt'i2e.7T Telephone 74 SC�Y'r5� <br />�cs�e,w� CouSuLTA^-�S Address ��� � �8`f 5�'`L'T�c -�i8/S�J.icense No. � ��1 � <br />lktiigncr . <br />Suil Log Hole No. 1 E /��/�'�"H — <br />Soil Log Hole No. 2 —. <br />Elecation of Water Table, if encountered. (Distance from ground surface) A�nA_,�'F--��-" ^l J/�.�T�`�'�� <br />Corrections to control surSace water if needed <br />Fill ncecicd: (AmounU _ ' �- , <br />P�rcolation: <br />Test Hole No. 1 Average Rate .5�� (Fall in min/inch-botrom 6" test holc) Ucpth test ta�<en <br />Test Holc No. 2 A��erage Rate e�G���Fall in min/inch•bottom 6" Iest hole) Depth test taken <br />'I'est liele No. 3 Averagc Rate (Fall in min/inch•boUom 6" test hole) Depth test taken <br />Accrrgc percolation rate on which to basc drainfield design <br />-� h� F� I nate taken <br />Scptic tank requirements Uased on present rules and regulations: <br />Septic 7ank Sir.c � �� , Qallons. <br />Amuunt uf Squarc Fect of <br />of <br />Nu Pcrmit Datc <br />posal Field _� 7e � <br />��, . <br />_INE (ro be completed b <br />Sanitarian_ <br />.�_ 1f - I`„ <br />�L.OIti� <br />Tr. Width 2� Tr. Depth_ I& ^�oRie�. e-���`r�" <br />Permit ro bc issued Date Sanitarian <br />Rechecked Sanitarian <br />agency) <br />Wet Wintcr <br />Check Received <br />Cash Received Permit Renewal <br />Called for hispcction Installer <br />Prrmi� iuucd <br />Parmit Numbcr � � / � - / � ---- <br />