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MOR <br /> ,� S�! _HOMISH HEALTH DISTRICT CITY OF <br /> 3020 Rucker#104 D <br /> Everett WA 98201-3900 SEC.63/GMA Compliance Required? YkEAUGNI 12 <br /> WaterlWastewater Section 425.339.5250 NAME: a Completion Date: / i <br /> REQUEST FOR A HEALTH DISTRICT CONSTRUCTION CLEARANCE AND/OR WAT 4U%W0nS <br /> Property Tax Account Number &+0000 `f 04) <br /> Owners Name: > /��N Phone: �Z� I �� TcQ( <br /> Mail Address: �-2 U ()ktie City: STI Zip: <br /> Contact Person: �l C r�IAD ,� Phone: <br /> Mail Address: U '� 1pt-A& City: �y �� Zip: �ZU� <br /> SITE ADDRESS: 2 H(AW6, CITY: E'� �e-TT 1 <br /> SITE LEGAL DESCRIPTION AND LOT#. 46 SP#/Plat name N4 � Mike Q 0 k �9- <br /> Is Septic System/Drainfield: X INSTALLED/EXISTING'` l 0 PROPOSED = NOT APPLICABLE <br /> *If installed/existing, approximate year of installation <br /> Has a new onsite sewage disposal system app cation been made to the Snohomish Health District in conjunction with this proposed <br /> building project? yes no. <br /> Indicate source of water: = INDIVIDUAL WATER SUPPLY Ik/P'UBLIC WATER SYSTEM <br /> Has an individual water supply application been made to the Snohomish Health District in conjunction with this building project? <br /> yesy no. C„�Q - ,➢, �4, <br /> Explain building project and its use (SFR, addition, shed, etc.): ✓y <br /> Is plumbing for any structures: EXISTING TOPOSED [ BOTH EXISTING/PROPOSED <br /> Indicate total number of bedrooms before and after construction: / RECEIVE <br /> M <br /> ATTACH A COPY OF PLOT PLAN-8 1/2"x 11"minimum showing: U <br /> 1. Dimensions of Property Lines. 4. Location of Septic Tank and Drainfield, if known. U(; 14 2011`7 <br /> 2. Dimensions of Existing Structures and 5. Roads, Easements, Driveways, Parking and Pavement rea`�. <br /> their distances from Lot Lines. 6. Location of Water Well. Snohomish <br /> 3. Dimensions& Description of Pr posed Cons ion. 7. North Arrow. Health District <br /> NOTIC :Aw' ee ay e Payable Upon Issuance of the Building P�mit <br /> SIGNATURE OF APPLICANT: DATE: <br /> FOR HEALTH DISTRICT USE ONLY <br /> WATER SUPPLY INFORMATION: (if Required By Building Department) <br /> 0 $100 GMA Drinking Water Determination Fee <br /> 0 Appears to be consistent with recommendations contained in "Guidelines for Determining Water Availability for New Buildings", <br /> issued April, 1993 as per Section 63 of Growth Management Act (GMA). <br /> �] Does not appear to be consistent with recommendations contained in"Guidelines for Determining Water Availability for New <br /> Buildings", issued April, 1993 as per Section 63 Growth Ma gement Act (see attached sheet for deficiencies). <br /> ONSITE SEWAGE DISPOSAL SYSTEM: $210 Field Review Q $105 Office Review <br /> Pl"'APPROVED = DISAPPROVED BY See Letter Dated <br /> Initial and Date <br /> CONDITIONAL APPROVAL: Conditions To Be Typed On Building Permit <br /> Q DO NOT FINAL STRUCTURE WITHOUT PRIOR SNOHOMISH HEALTH DISTRICT FINAL APPROVAL <br /> Q OTHER <br /> BUILDING CLEARANCE APPROVED: BASED UPON REVIEW OF THE ONSITE SEWAGE DISPOSAL SYSTEM <br /> INFORMATION AND, WHEN APPLICABLE, THE WATER SUPPLY INFORMATION. <br /> REVIEWING SANITARIAN: DATE: Z, <br /> 957.0 P t • L�/ L 9MON11SOd <br /> 01 Rev Effective 1 10109ss <br /> 7� L.v <br />