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[:�,cr.}��r��l�i�[1UL�D `� <br />� SNOHOMISH HEALTH oisTRiFr, MAY 0 q Zp �ZI'.Q�II�:S'1' F012 RI:YOKT ON AN <br />WaterNdastewater Section �;.:.� Q�NSI'17�: 51�;1VAG1�, UISNOtiAl, S1 ti 11 11 <br />3020 RuCker Avenue tl104 y�y,p�� ❑('hccA box dappGctlion induJe} �I';ucr Rcpor� Rcyuctil <br />EvereUWA98101-39Pl�EFAIiC)NS 8 �^ama �nd:ulachcumplctedapphcauon <br />� 425.339.52�0 hqqIN�ENANCE �"~� <br />Property Tax Account tL� '� 0 51� �' � 3 n 5�� n0 <br />PropertyAddress � ' Z /�'/ Si" SL Ciry �� v�.ci=T.J <br />MAIL REPORT TO: Please cle:f�_RrLn lul amc 8 <br />� <br />comt�lel d�1R�cludina zin codr, � <br />/%i/rLN'��=� /�'li5/- /.v���%.vi=�jii�t�G. �%C[:��I' <br />ame , <br />3�C'0 Cr�D�ts'� ST <br />Address � <br />/ r�F:,��yT %�ust�c 4!at��P•f?�?/ <br />Cdy/St2ip <br />Legal Description: Sec. Twp. Rng. Lot N L <br />no'f ��ni.ln <br />UNI.P:titi <br />,V'1'I.IC,17'ION <br />Iti U�1'17i � PF:F: <br />SP�\1I1'I�:U Itl' <br />s��ununitsn <br />111{,U:1'ii <br />���he����N�JFI <br />SHD OFFICE USE ONLY <br />3te:05/10N6 kk:301 11:43 arn <br />lerk: �09 lmreiceN ?ni�OgiOi� <br />SuG-Tr,tal: 186.U0 <br />Tot�l: 19o.Cn) <br />lr,ors-205o , 14b,nq <br />Ch.nge: O.UO <br />1 tAA.QQ <br />ly�licanCsNarra `.��••✓ /z i'�'�•-Ja.✓ Phono �Z� - � �3 7 - 17cS <br />axiei'sName �•t•"��=-. Phane �/1 .S'l 235'-JC•z_/ <br />Is houso occupied? j�Yos ❑ No II not, dato vacaled <br />Year house built ��� `� Number of bedrooms � _ <br />Date septic tank last pumped �--� �' �' � Pumped bv i%� i= A r�.•Me -S'� i- l2. "-v=.['✓,z�. <br />Has lhe septic system lailed or mallunc�ioned^ ❑ Yes ,QQ No Explain <br />Has tho septic system been repaired or altered? Qi'es �No <br />Since new, has tho home had any additions? ❑Yes �lo <br />Applicant Signature <br />/ t''4.. <br />Date <br />NOTE: Any lield rnspecfion conducted hereunder is limited to a visual inspecfion o/ fhe site to observe signs ul sepfic <br />sysfem lailure present on tho ground suAace or suAace wafer, and visiblo physical leatures which may impair the proper <br />operation of the sepfic sysfem. This report does no; constitufe a representafion, warranty, or guaranfee az to whelher or <br />not fho sysfem is acluallylunctioning af thfs fime, nor represenfafion or warranty as to the lu�ure (unctioning o! the sewage <br />disposal system. <br />l�or llcullh Dislrict sc Only <br />Fiold Inspection [)ata �� As•Built on filo. <br />1.�ewago disposal system ppoars to be functioning at time ol inspoction. <br />0 �s-Built not on lile. <br />2. O Sewage disposal system appears to bo malfunctioning at time ol inspection (owner to be notiliod). <br />3. � Home vacant at �imo ol inspection, system not in operation. <br />4. �nohomish Heallh District records indicato that tho septic tank has not been pumped within tho last 2 1/2 - 3 years. <br />5. (�Thora appears to be a portion (approx. �_ fe9Q ol drainliold located un�'er �� �/Cf� • <br />�� <br />Comments <br />I 7c• <br />Signed ����-'��b`—('� ` \ � � 1 �-� � , �T�( � Dalo <br />Lrivnonmontal Hoalih rvi;on IID ^7 reNIN2A03� <br />b�S' <br />