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� St�OHOMISH HEALTH <br />Walor/Wastewater Section <br />3020 Pucker AvQnue q104 <br />Everott WA 98201•3900 <br />425.339.5250 <br />DISTRICT �irQursr roti iirirorzT orr nN /� <br />o�vst��t: st:�vnct: o�sr�osnr, svsT�cn� <br />j��j ChccA box if applicatiun includcs R'atcr Rcpurl Rcyucst <br />U and allach cuniplctcd applicalion <br />Properly Tax Account It � n0 S' 9t! - 000 -OOS - � D ,/ <br />Prope�yAddress�Dn� /�7.�T� ���e SE Citv E�ere7� iB.LC�4 <br />MAIL REPORT TO: P�oaso cicariv o�_�I�i.ur g_$ <br />���T ����•��� I SHD OFFICE USE ONLY <br />UNI,I•:tiS <br />c�o I .dr�ssincludinazinco�q, � pp���,�CpTION <br />Lv/e E G%�i r_/� � o_ / �s nn��i: s ru:H: <br />am tiTA;111'1?U 145' <br />�i Do 9 /,�,Z.../ f�/ac� S�'' SNOIton1I5�I <br />ddres�/f /,�J�4- q8.7 o g ur•.ni.in <br />cnyis� i A _ f�...���11� L4� <br />%�4�',b4.'re !r.�fs �>' <br />L�al Descnption: Sec. 1 wp. Rng. _ Lot N..� 5 <br />ate:04/28/06 P.N:301 1:�1 pm <br />lerkt 30'� InvoiceM S90Q86503 <br />Sub-Total: 186.U0 <br />To ta 1: 1 BE .O�.l <br />esi gr1258 : 1 A6.n0 <br />Change: 0.00 <br />, ,a<..al <br />/1pplicanYsNarra /�/� E Lr1,�p /� l Phone �/,Z �,�,J 7— 7 Y/,¢ <br />O�vner'sNvne �y/� � L.!� �-l�.l�/ Phono Z D L 390-0 7/7' <br />Is house occupic�l? �f Yes ❑ No II not, date vacated <br />Year house built ,L,� % — Numbor ol bedrooms .3 <br />Date septic tank last pumped ���.�— Pumped bv A w_ e rce S��i�.'n f.-�, «_/., �. <br />Has iha septic system failed or mallunctioned? ❑ Yes � No Explain <br />Has the septic system boen repaired or altered? �es ❑ No <br />Sinco new, has tho horr�o had any addilions? �Yes ❑ N� <br />Appficant Signaturo <br />Describo�w,.�// ., �« ,�Jac c � <br />Date t.�/ z a <br />NOTE: Any !ie!d ir��ection conducted herounder is limited Io a visual inspection o/ the sife fo observe signs of septic <br />sysfem lailure prosent on fhe ground suAace or surlace wafer, and visible physical leafures which may impair !he proper <br />operation ol tho septic system. Thi� report does nof constifufe �� reprosentation, warranty, or guarantee as fo whether or <br />not the systnm is actually lunctioning af this time, nor represenlafion or warranty as fo the luture luncfioning ol (he sewage <br />disposal s}stem. <br />l�or licnllh llislrlcl Usc Only <br />Fiold Inspection Dato � � �As-Built on lile. � As-Built not on file. <br />1. � Sewago disposal sys em appears to bo functioning at timo of inspection. <br />2. O Sewage disposal system appears to �o mallunctioning at timo of inspeclion (owner to be notified). <br />3. ❑ Home vacant at time of inspection, system not in operation. <br />4. � Snohomish Health District records indicato Ihat the saplic tank has not be�:n pumped within the last 2 1/2 - 3 years. <br />5. �1 There appears to be a portion (approx. �_� leet) of drainfield loc2,ted under C� C.U�� C f[.�f _ <br />Comments <br />._ .i�, ,/ <br />Date �L1 � <br />T i�u �� �«+�xzao����� <br />�o��� Si <br />