HomeMy WebLinkAboutSEP1972-00201 6(t') r( 2, -6° k
' 903 Est Caroline OLYMPIC H,6ALTH DISTRICT Permit No. 5 OS` f
P-ort"Angeles Fee Paid $ fS c'(.'
SEWAGE DISPOSAL PERMIT APPLICATION
Submit in Duplicate
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' 111147 ..w� I►�1IIwI�Arr ADDRESS P l), / )(..' K < DATE //2c/7z
LEGAL DESCRIPTION \-_ A\.LZ,,, K tkKi l U PHONE
DIRECTIONS FOR LOCATING SITE -\ . w� � `s .a`>'l ,\ � \
APPLICATION IS HEREBY MADE TO: INSTALL NEW SYSTEM -"--REPAIR EXISTING SYSTEM.
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YYPE`OF BUILDING HO. OF BEDROOMS BASEMENT SITE SIZE NAME OF INSTALLER_ .
. -ON THE REVERSE SIDE, DRAW A DETAILED PLOT PLAN GIVING THE FOLLOWING INFORMATIC v.
1. Property lines 7. Driveways, patios, carport, etc.
2. Location of building $. Streams or bodies of water nearby
3.: ocation of septic tank
P 9. Location of percolation test ho1ec j
4.- Location of drainfield 10. Septic tank size / -X- ' gallcr
5.. .Slope of land 11. Length of proposed rainfield
6,-Water lines & well(if applicable) 12. Depth to water if e countered.
PERCOLATION TEST RESULTS <>- r--
Depth Time required to Percolation rate Type of soil
of hole ° seep last 6 in. (divide time bye g7
Perc. No. 1 r. \,
Pere. No. 2
Perc. No. 3.
DRAINFIELD LENGTH /3 WIDTH DEPTH Y NO. OF LINES A\
IT IS HEREBY AGREED THAT THE PROPOSED INSTALLATION WILL BE MADE IN THE MANNER 2
AS-DESIGNED AND APPROVED ON THIS APPLICATION.
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Signature of Applicant
APPROX. DATE OF INSTALLATION S u:4F.��5
SANITARIAN'S COMMENTS:
:IS_CONSTIT.' ' ' 'E'MIT WHEN HEALTH OFFICER'S SIGNATURE APPEARS AS APPROV,'`
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PLAN APPROVED /� r.
MIL
� DISAPPROVED DATE l ��vCls
DATE__INSPECTED 7 L `, L SANITARIAN:. ..x VvIk
REMARKS:
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I CERTIFY THAT THIS SYST- i oAS INSTALLED IN THE MANNER APPROVED BY TNT' Hti.LT -4)
DEPARTMENT.
INSTALLER' S NAME DxT2