HomeMy WebLinkAboutSEP1972-00197 3 ) ti2-Do RI
East Caroline OLYMPIC HEALTH DISTRICT Permit No. 'S/C) `).-
P Angeles Fee Paid $ 4714c,4-
SEWAGE DISPOSAL PERMIT APPLICATION
Submit in Duplicate
NAMik ' ADDRESS :\ DATE 8 ////77--
LEGAL DESCRIPTIONw PHONE ,_
DI I FOR L C NG SITE ie" -*-4: _ _ �`4 A
APPLICATION IS HEREBY MADE TO: INSTALL EW.. w '= 'EPAIR EXISTING SYSTEM
Q\ Qom. , ...E
AMONINONIFIONOR
E OF BUILDING NO. OF B1DROOMS BASEMENT SITE SIZE NAME OF INSTALLER_
_ -ON THE REVERSE SIDE, DRAW A DETAILED PLOT PLAN GIVING THE FOLLOWING INFORMATI(
1. Property lines 7. Driveways, patios, carport, etc.
2. Location of building 8. Streams or bodies of water nearby
3-..„„Location of-septic tank 9. Location of percolation test holes
4._Location of drainfield 10. Septic tank size gallr�n'
.,._Slope of land 11. Length of proposed drainfield
6,_ Water lines & well(if applicable) 12. Depth to water if encountered.
PERCOLATION TEST RESULTS
Depth Time required to ' Percolation rate { Type of soil Vk'
of hole seep last 6 in. (divide time by 6) #
Perc. No. 1 i t'1-7'4 2
Perc. No. 2
Perc. No. 3.
DRAINFIELD LENGTH 1 :;()' WIDTH DEPTH NO. OF LINES .L- • s
IT IS HEREBY AGREED THAT THE PROPOSED INSTALLATION WILL BE MADE IN THE MANN
AS- DESIGNED AND APPROVED ON THIS APPLICATION.
)
Signature of Applicant
APPROX. DATE OF INSTALLATION t`- / R q / ; 2_ C
SAMTTARIAN 'S COMMENTS:
THIS._CONSTITUTES A-- • RMIT WHEN HEALTH OFFICER'S SIGNATURE APPEARS AS APPROVE_
PLAN APPROVED DISAPPROVED DATE
DATE_ INSPECTED C z `,•CL LANITARIAV4..
REMARKS:
I CERTIFY THAT T. �,, T "I 'wAS INSTALLED IN THE MANNER APL-RCVED BY THE H.i�.. -11'i'
DEP.4 RTTNT. - �_INSTALLER' S NAME i" D�zTL
5-ii 'C-C Kt'