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YC�S� Ca �� �3�F02E Go�tiG o�-tT y <br />,/ 4 SNOHOMISH HEALTH DISTRICT REQUIsST �OR RLPOR7' ON AN <br />L Water/Wastewater SQction ONSITI; SGIVAGI�, I)I5P05A1, SYSTIiDT <br />3020 Rucker Avenue N104 Check bos i(appGeatiun includcs \1'aler Rcpurl Rcyuesl <br />Evorott WP. 98201 •3900 <br />� 4�5.339.5250 and auach complcicd :�pplicauon <br />Property Tax Account �� ��� pL'� OL <br />Property AdcJress a� � � /�5��_cy,�.o <br />MAIL REPORT TO: ��''���'��%u'-'��'I�n�me g <br />pl4 /r ncludina zio co�g, � <br />u��� 4 ��7 � . ,�'�' rss ` <br />Na e " /� <br />/ � �t � r� <br />�'�� re �f" a <br />�dy/5t/Zip <br />Legal Descnption: Sec. Twp. Hng. Lot s <br />Ap��ranrs Name /,l,%I /!ia {,? 1 _ , ,a�l�'/2 <br />pv�ners N�mo <br />Is house occupied? � Yes ❑ No <br />Yoar house built � � � �f � <br />Date septic tank I�st pumped <br />II nat, date vacated <br />Gry �✓e r'C�/ <br />NO'I' 1'A1.11� <br />uut.r:ss <br />API'IJCATIUN <br />Iti DATI•: & Pliti <br />ti'fA:1f19iD Itl. <br />tiNUllll\Iitill <br />ui•:n�, rn <br />U�1 ST It�l (� f �, ., <br />SHD OFFICE USE ONLY <br />r.�:-:ii1/i�:i'/;-i, fiq:'ni �;�=,1 ;,, <br />I�s��4.: ;!i Invoi�=ep ?ti�ll�:�'117 <br />;�b-Tot.sl: 13�.,�� <br />Torii: t,.;.r-i. <br />� <br />Ch3nve: <br />t=. .�; <br />L_ti .0 ` <br />Phone �� —�� 7 ��� <br />Phond �� <br />Number of bedrooms� <br />Pumped <br />Has ihe septic system failed or mallunctionod? ❑ Yes � No Explain <br />Has the septic system b�en repaired or allered? QYes �No <br />Since now, has the home had any addilions? �Yes �No <br />NOTE: Any lield inspection conducted hereunder is limifed to a visual inspection ol the sifo to observv signs o� septic <br />systom lailure presenf on the ground surtace or suAace wafer, and vis,blo ph, sical leatures which may ;'mpair the proper <br />operafion ol Ihe sepfic system. This report does not consfifute a rcpros��ntafion, warranfy, or guarantee as to whethar or <br />not the system is actually luncfioning a( this fimo, nor represenfation or warranty as to tho luture f�nctioning o/ fhe sewago <br />disposal sysfem. <br />i�ur lleulth Uislrict Use Only <br />Field Inspection Dato _�I O� �As-Built on file. � As-Built not on lile. <br />1. �] Sewage disposal system appears to be lunctioning at time ol inspectlon. <br />2• � Sewage disposal system appears to bo malfunctioning at time of inspection (ownor to be notilied). <br />3. [_] Home vacant at time of inspection, system not in operation. <br />4 O Snohomish Heallh Disirict records indicate that the septic tank has not been pumped wilhin the last 2 1!2 - 3 years. <br />5. 0 Thore appears to be a portion (approx. leet) of drainlield located under <br />.� <br />� T 2 <br />Signed — /t�� ����'� u Date � /� 0 T <br />[n nomm�ntal Hnnl � Drvi9nn IIU :7 iedi82A021 <br />�I I. <br />