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1 <br /> SNGHOMISH HEALTH DISTRICT <br /> Environmental Health Division <br /> Courthouse, Everett,Washington 98201 <br /> APPLICATION FOR A SEWAGE DISPOSAL SYSTEM PERMIT <br /> I Submit 3 comesl <br /> Accl.No.3t? 6 - 000- 005'—000 G <br /> Permit to be issued to D D L P f' / 1V 1-4 OM C S <br /> I <br /> For installation at (street address) - 317 77 s-N P4. S w ✓E K2= 77- <br /> Scc.Le'LTw•p7,LRg._�f_Short Plat No.--Lot—plat 64'_*G/S NO 3 <br /> Lot SBIk._ <br /> Type of Building: New ✓ Existing_Single family residence ✓ No. bedrooms 3 <br /> Water Supply: Public Private Other: (specify type or use) <br /> BuilderpOL PN /N 140AICS a 116T" <br /> Sr. <br /> A/, I{/ ll(� ST ScATTLeL Telephane,� 3^ 20/2 <br /> ^ 7::7 S4HM I D - 1?7a7- gq-rY Av_e w. <br /> 9. ddrcss L Ira<M«4.00.I—�8��o t icense No. �4 3 76 <br /> lo. t O - It G R. S A A/p y L-v A Ate/ <br /> i n <br /> "able, irencountered. (Distance from graund surface)— <br /> u Eo t o d surface water if needed <br /> z <br /> C:) M <br /> C::; C:) t) <br /> * -age Rate (Fall in min/inch-bottom 6" test hole) Depth test taken <br /> age Rate (Fall in min/inch-bottom 6"test hole) Depth test taken <br /> icx note Ivo. d Average Rate -� (Fall In min/inch-bottom 6" test hole) Depth test taken Q 4 - <br /> Average percolation rate on which to base drainlield design 3n' /A�n pate taken _"0/Z 7e <br /> Septic tank requirements based on present rules and regulations: <br /> Septic Tank Size 1000 _gallons. <br /> Amount of Square Fcet•o(Disp al Field 3 y s _Tr. Width Tr. Depth � ' <br /> Signature of Designer.. ��. r _ Date _0 7 P _ <br /> DO NOT WRITE BELOW THIS LINE (to be completed by issuing agency) <br /> No Permit_Date dldll Sanitarian 1 ' Pending _..C.•- JL <br /> Permit to be Issued X _Date 'f'I '' w Sanitarian <br /> Rechecked__ Sanitarian Wet Winter Months_ <br /> Check Rccci%cd Cash Received Permit Renewal <br /> Called for Inspection_ Installer <br /> Permit issued (date)_ _ �� " Permit Number <br />