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y. SNOHOMISH HEALTH DISTRICT <br /> t Environmental Health Division <br /> > ^ Courthouse, Everett,Washington 88201 <br /> APPLICATION FOR A SEWAGE DISPOSAL SYSTEM PERMIT <br /> [Submit 3 copiusl <br /> Acct.No.-`i IV —as DO 6 ' OoaS <br /> Permit to be issued to <br /> r It <br /> For installation at (street <br /> ttlladdress) 77 C�� 5 . l� E V� !�C Tr <br /> Sect_LTwpZ_1Rg.q_Short Plat No.—Lot—Plat G1 S 'VD Lot�Blk. <br /> Type of Building: New L/ Existing_Single family rcsidcnce No. bedrooms <br /> Water Supply: Publicy Private Other: (specif,, type or use) <br /> ST <br /> rl/ ZU/7i <br /> I— BL /-/DA,f�� address A'01n� Al w 116 1�R f 1 44' Telephone�� y <br /> .nr !r, <br /> 1`Address —1.iccnsc No <br /> i oy n , I O— Sl 6�. �N A,aY, !�i'1 <br /> Z ds 1d 3 ,7 . y of <br /> a ableif encountered. (Distance from ground surface)_. _ <br /> y 7gtt � sl surface water if needed —_-- <br /> N 71t <br /> 1t) <br /> Yrnuu...... . <br /> Test Hole No. I a Averag Rate 3 (Fall in min/inch•bottom n" test hole) Depth test taken <br /> Test Hole No. 2 Average Rate—�_ (Fall in min/Inch—bottom 6" test hole) Depth test taken —2n ' � <br /> 'rest Hole No. 3 Average Rate (Fall in min/inch-bottom 6" test hole) Depth test taken �D <br /> Average percolation rate on which to base draintield design_ •4 01 L'^� --Date taken <br /> Septic tank requirements based on present rules and regulations: <br /> Septic Tank Sire e6C0e2 _gallons. <br /> Amount of Square Feet of Disposal I'ieldL—Tr. Width Tr, Depth <br /> Signature of Designer_—, Date •�U <br /> DO NOT WRITE BFLOW THIS LINE (to be completed b) issuing agent)) <br /> "} + <br /> No Permit _ _ll,nc'_ (____Sanitarian Pending___ _..._."^`' _ <br /> Permit to lie issuc('.._,,-_—--DateCIM ' " _Sanitarian <br /> Rechecked _ Sanitarian Wet Winter Months <br /> Check Received Cash Received Permit Renewal_ <br /> Called for Inspection Installer —_ — <br /> Permit issued (date) /Q �a — 7 Permit Number <br />