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SNc HOMISH <br /> HEALTH DISTRICT • <br /> '., WWW.SNOHD.ORG Water and Sewer Adequacy/Food & Community Safety <br /> Facility name Lel "I { (_. ca-0-5,4-4,_ <br /> HEALTH DISTRICT <br /> / USE ONLY <br /> Site address / 5- Z3 / 5/� <br /> City State ZIP <br /> Y` r <br /> Parcel number Proposed number of seats <br /> Contact name /----.-7-/--6--1-'-i #1- -/,',S Phone -%6)-%/-24.-/--3) <br /> Email/< C(--1 '%? ') �" Com/ Fax <br /> ❑ New construction U Remodel/Alteration U Expansion of existing restaurant <br /> _ <br /> ❑ Yes . I -No Is facility connected to a septic system? <br /> ❑ Yes Are public restrooms available? ❑ Pre-approved water system <br /> ,rr.Yes ❑ No Is a grease trap required by sewer district or building department? <br /> Describe the proposed project: y , <br /> Sewage system ❑ Sewer bill attached ❑ Below completed by official <br /> This section should be completed by a Public Sewer System Official, if a sewer bill or availability letter is not provided. <br /> Name of system C.. .(7 P g� Sewer utility <br /> The above system will provide service to the facility listed at the above address. <br /> System official Phone //2S---2-5-7 - t c:-,c Date <br /> Water system <br /> This section should be <br /> completed� by a��c Water System Official, if a water bill or availability letter is not provided. <br /> Name of system t. 77 ✓�lC �C� State ID number <br /> The above facility )is connected ❑ has applied <br /> The above system will provide service to the facility listed at the above address. <br /> System official Phone Date <br /> HEALTH DISTRICT USE ONLY <br /> On-site <br /> Approved to submit(signature) Date <br /> Final septic approved (signature) Date <br /> Water <br /> Name of water system State ID Number <br /> ❑ Not adequate for use <br /> ❑ Adequate for use (signature) Date <br /> Comments <br /> Environmental Health Division <br /> 3020 Rucker Avenue,Suite 104 ■ Everett, WA 98201-3900 ■ fax:425.339.5254 ■ tel: 425.339.5250 <br />