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, <br />� <br />......---• <br />SNOHOiiIIIS!-I !-°EALT� DISTRICT <br />Envlromm�ntal Health Divlsion <br />� Courthoueo, Evorett, We�hington 98201 <br />APPLICATION FOR A SEWAGE DISPOSAL SYSTEM PERMIT <br />, I Submit 3 copicsl <br />Acct. No. <br />i�3ri—OOn_n'�::_-, • <br />Pcrmit to bc i�sucd to _.� ��� •-_ �'.lill ��V i^al'-`r <br />For installa�ion at Isvcct address) �=�7 :ion��:• 1i.t :'e �ic:� i <br />.;?'c ��"�'itC;rri) <br />Scc_Twp.—Rg.�Short Plat No.__Lot_Plat <br />Typc of Uuilding: New_ Existing_ Single (amily residence No. bed <br />� <br />Lot_ Blk. <br />Water Supply: Public ^ Private Othcr. (specify qpc or usc) _ <br />Buildcr"•Sti'�.-•;1eClttlel' Address -,�^r::��r.�� 'd;ip, iiv�r�tt Tclephore ''''-' ;�)� <br />J. d. '''ni nl Ct �:0. .���r � ROCK°1�^IZ•?1' Ave. �::V^..^CY,f; ; '' .. <br />Designcr Address _ �-iccnse No. ' <br />Soil Log Holc No. 1'�-i� ��'"•�-.; c Lnari; U..�u "an:i R^rs�el <br />Soil I.og Holc No. 2'�-3 0^:•3n'_�� La3:-; i'3? St�.^.�: °� �ra�:al <br />Elc�ation'o( Watcr Ta61c, if cncountcred. (Distancc from ground <br />Corrcctions lo comrol surface u•atcr if necdeA 'loti' <br />;7on� <br />Fill necdcd: IAmaunU :lof.? <br />Pcrcolation: <br />Tesl Holc No. I A�cragc Ratc 1j (Fall in min/inch•boitmn G" tcst holc) Depth tcst taken <br />Tcsl Nolc No. 2 A�cragc I�atc�_' (Fnll in min/indi-bouom 6" tcst iiole) Dcpth tcst takcn <br />Test Hole No. 3 A��erage Ratc ' (Fall in min/inch•bm�om G" test holc) Dcp�h test taken <br />8 <br />Avcragc percolatinn ralc on Nhich to liasc drninficld dcsign � natc tnkcn•7�i" '� '• ���7 <br />Septic tank rcyuircments bascd on prescnt rulcs �nd regulations: <br />Scplic 1'ank Sixc � � � i _gnllons. <br />Amount of Syuare Pcct uf Disposal Ficld _��Tr. WiAth � '�� Tr. Dcpth '� _ <br />' � � � %� <br />, ri;;7� � / �"�7 . 1`/< GC_ /-_ ' Datc ._ � � 7� .., <br />Signa�urc of Dcsi4ner----_- — <br />DO NO"I' \Vltl fli ISLI.U\V '1'HIS LING Uo bc completcd b� issuing agcncyl <br />No Pcnnit —Uate Sanitarinn <br />Pennil lo bc <br />RechecAeA Sanitarian <br />Chcck Rcrciced <br />i <br />, _..� �.-� , <br />� �� �_�-' �j_'% =��," ,/�i�'7 <br />_ . ,�: ' <br />Wcl Winlcr <br />Rcccircd Pcrmil Rcnc�ral <br />Cnticd f„r hispriKinn Installcr <br />f4�rmi1 i�+urd Id:nrl_ ��/y/7� <br />/ <br />Pcrmit Numhcr <br />r <br />��� <br />