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�SNOHOMiSH HEALTH DISTRI` <br />3020 Rucker q104 <br />Evcrett WA 98201v^900 <br />WaterlWastewater Sectlon 425.339.5250 <br />REQUEST FOR A HEALTH DISTRICT <br />� � � � " " � DS PLAN CHECI; C �� � O� G �/tie ii- ' <br />JAN 1 1 200Z SEC.63/GMACamplianceRequired7 YES O N0� <br />Snonom�u� PDS NAME: <br />CON9�fd�Ts(4,1N CLEARANCE AND/OR WATER SUPPLY COMMENT ii <br />_"_'I <br />Property Tax Account Numberl OG t� :/� �(7 t7 ( O 1 <br />Owners Name: �T�. N P�r � n>oN Phone:, ���5 ��SS - 6a S( o <br />� GY2F'T% Zip: �! <br />Mail Address• '�nr'O /aT ��' AVE. !,�J. Ciry: _��,. �� o y <br />Contact Person: Phone: <br />MailAddress: �i�i��0 I�i���� L��)� '� City: �',�c�t2=7'� __ Zip• CI�1.�.-^+y <br />SREADORESS: i�IO� ���T �� 1L,L' �J CfTY: rG �/F14 L'lTr <br />SITELEGALDESCRIPTIONANDLOTN: y�a� 1=1 SPN/Platname"r ci ri�r�e,2�^EU 'rRe�T� <br />Is Septic System/Drainfleld: � INSTAILED/EXISTING' 0 PROPOSED 0 NOTAPPLICABLE <br />9f installed/existing, approximate year of instaliation ��� 7 <br />Has a new onsite sewago disposal system application been made to the Snohomish Haalth District in conjunction with this proposed_ <br />iUlc�nr pMvicp�/ 6f/ I3hi�Lf'to <br />building projecCt �S._ Yes _ no• ,Sj Gla7`�r �iSf O,t � Su6r� r G <br />Indicate source af water: (� INDIVIDUAL WATER SUPPLY � PUBLIC WATER SYSTEM g�'�'� ��'�J <br />/�fi(�rpH �'O <br />Has an individual waler supply application been made to �he Snohomish Heallh District in coniunction with this building project? �/-{�/O� <br />Grii��� <br />— yes X no. _ _ C����1�"y"�O�" <br />Explain buiiding pro]ect and its use (SFR, addition, shed, etc.): -' <br />Is plumbing forany structures: QEXISTING OPROPOSED � BOTH ECISTING/PFOPOSEU 5��� � <br />Indicate rotal number of bedrooms hetore �� after construction: ^ / � mO�fe �' <br />ATTACH A COPY OF PIOT PLAN - 81/2" x 11" minimum showing: <br />t. Dimensions of Praperty Lines. 4. Lacation of Septic Tz %7uB��� �/0%�S <br />2. Dimensions of Existing Slructures and 5. Roads, Easements, <br />lheir distances from Lot Lines. 6. Location of Water Wi � <br />3. Dimensions & Description of Proposed Construction. 7. NoRh Arrow. _ <br />NOTICE: A Review Fee May-Be ayable Upon Issi Ki�k BfookS (•�25125� s?'�'. <br />F �� � f Dave�opmenfsandPermds Pax(�t25):�Si'985�� <br />SIGNATURE OF APPLICANT: � J� - -'-"— pa•md Sarvices Manager khrnoks�i�a evcren.�.va �is <br />FOR HEALTH DISTRICT USE <br />WATER SUPPLY INFORMATION: (If Required By Building Departmi �ngineermg / Pubiic Services Depanmen� <br />CiTY OF EVERETT • 32C0 Cedar Sireet • Evereu.':'��� 992Ut <br />❑ Appears to be consistent wilh recommendalions contained in "Guidelines for C _ . - <br />issued April, 1993 a� per Sectien 63 of Growlh Management Act (GMA). <br />Q Does not appear to be consistent with reccmmendations contained in "Guidelines (or Determining Water Availability for New <br />Buildings", issued Apri�, 1993 as per Section 63 Growth Management Act (see atlached sheet for deficiencies). <br />QNSITE SEWAGE DISPOSAL SYSTEM: <br />❑ APPROVED: <br />� CONUITIONAL <br />0 DISAPPROVED; <br />REVIEWING SANITARIAN: <br />� -•'- - �� • � �� . <br />DATE: <br />BUILDING CLFARANCE APPROVED: BASEDUPONREVIEWOFTHEONSITESEWAGEDISPOSALSYSTEM <br />INFORMATION AND, WHEN APPLICABLE, THE WATER SUPPLY INF RMATION. <br />REVIEWING SANITARIAN: C.��Lt�" �� DATE �•�� �� "V O"" QY <br />rcvl2/1/99j •�1�L\ j� <br />�I7i �. <br />