HomeMy WebLinkAboutSEP1974-00287 . itap h, / �c 4�-- �E-p 9 L�_ x.57, c ..z.,„:7s„i
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903 E. Caroline OLYMPIC HEALTH DISTRICT ct- Permit No.
Port Angeles SEWAGE: DISPOSAL PERMIT APPLICATION
Submit in Duplicate Builder
• Court House
Port Townsend Date 9/(7 Ay
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DIRECTIONS FOR LOCATING SITE \4,—.. -`- z, "N...
LC.90 & )
APPLICATION IS HEREBY MADE TO. INSTALL N34 S .TEM °PAIR EXISTING SYSTEM
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NDF TYP F 1g N . _0F B �R OMS BAS ENT NA : OFNSTALLER
DRAINFIELD LENGTH/3c); t'IDTH ( DEPTH t°" #LINES SEPTIC TANK SIZE Q.,
DRAY A DETAILED PLOT PLAN BELOW. SEE INSTRUCTIONS. SOIL TYPE c� `S� N.. '1 r=te.`
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-ANY CHANGE IN BUILDING OR SE' AGE DISPOSAL PLANS, LOCATION OR SITE, INVALIDATES THIS
PERMIT UNLP S PRIOR APPROVAL OBTAINED FROM THE HEALTH DEPARTMENT.
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DATE OF INSTALLATION
SIGNATURE OF APPLICANT 4 ''.. . ,f A
AP REED 4.------------
DATE 7//126 INSPECTED BY DATE '/ 2
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SANITARIAN'S CORNETTS: k `
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I CERTIFY THAT THIS S 11 M ' AS INSTAL D , 'i MIO, ER APPROVED BY THE
HEALTH DEAPRTMEIIT RATE
INSTALLERS N:ME �--�
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,�(1 "r JEFFERSON COUNTY PUBLIC HEALTH
Visit Dates: 1Pcl ((S
Fy ,,C° Onsite Sewage System Sanitary Survey
PROJECT:
SITE INFORMATION EIGHBORHOOD:
Site Address: 2c tZ -C�;C tj G ( Occupant:
Parcel#:c 52. 0 2 Phone: . O `3 o ( ? °
Owner: JUN.'S iZli 1 YtS-� Email:
Mailing Address: # of Occupants:
Full/part time:
Phone: # of Bedrooms:
Email: Water Supply: Well / Public
Water Meter: Yes / No
SEPT YSTEM INFORMATION .
Per ' / No $ it- 7 .. s:
SEP #(s) Plumbing leaks or backups: Y 6
System Type: O&M Schedule: Annual / 3 years
Install Date: 40 J s t Laundry: per day/wk t
Altered/Repaired: Fabric soft- I -r: Yes / No
Last Pumped: ti(�( - 3(Jt'O Additives' ��, No
Last O&M: ) `°� Animals: Yes No
PLEASE: DON'T FLUSH CHEMICALS,MEDICATIONS OR TOXICS INTO THE SYSTEM
WALKAROUND
OSS condition: Surface wate nearby: (type)/ N
Roof drains: Distance to a ,.infield
Other drains: Reserve:
Concerns:
FINAL RATING - Staff: /t1�>
ENo Problems (Suspect Failure
STATUS �� ,�-� �,�/,- (,,,. ����� +jam
L'e`i nse J
❑Completed EAttempted-Denied Access gii • ttempted-No Response
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