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SNOHOMISH HEALTH DISTRICT <br />Envlronmerdal Health Mitten <br />Courthouse, Edarattt Washington 99201 <br />APPLICATION'FOR A SEWAGE DISPOSAL SYSTEM PERMIT <br />j � I Submit 3 copies) <br />Permit to be Issued to <br />For instalintion at (street address) <br />_C4 <br />See._Twp._Rg._SShorl Plat No._Lot—Plata l)Edir 84dA.I '^ -4rec Lot_2)�Blk.L— <br />Type of Building: New__L Existing_ Single family residence_ No. bedrooms -? <br />Water Supply: Public_ K Private Other: (specify type nr use) — <br />....,,..__ Y.'Aie NIA LAaZoi�Ad,lr, . 9939 1?6 ,k,- r/li/ Telephone 2) - />00 <br />Designer dUsddress_C4A / XX /a 4 r a/25 License No. / 7 Y <br />13r�: L M �ti `—�1 a <br />Soil Log Hole No. 1 � '� u-��'�' � `JAZ— <br />a <br />Soil Log Hole No. 2 _ /- i y� L— �f "� fe.✓ 4 / M — <br />Elevation of Water Table, if encountered. (Distance from ground surface) AAdw, <br />r <br />Corrections to control surface water if needed <br />Fill needed: (Amount) <br />Percolation:_ <br />Test Hole No. 1 Average Rate (Fell In min/Inch-bottom 6" test hole) Depth test taken _ <br />'Pest Holc No. 2 Average Rate _? —(Fall in min/inch•boitnm 6" test hole) Depth test taken <br />Test Hole No. J Average Rate_? (Fall in min/inch-bottom 6" test hole) Depth test taken S <br />Average percolation rate on which to base drainfield design `r ^' 'Date taken !ram. <br />Septic tank requirements based on present rules and regulations: <br />Septic Tank Size !V d _.gallons. _ 11 <br />Amount of Square Feet of Disposal Field ,�Tr. Widths-2 N Tr. Depth 3 <br />of <br />No Permit <br />Permit to be issued —late ' K y" �Sanitarian <br />Rechecked _—Sanitarian Wet Winter Months <br />Check Received Cash Received Permit Renewal <br />Called for Inspection__ Installer <br />Permit issued (date) <br />---F , dr 741----____ ....-Permit Nimiher -7/ ,j 0- <br />