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�'f JEFFERSON-COUN4Y HEALTH DEPARTMENT 5.-6-P19-621-1
INSTALLER 802 SHERIDAN AVENUE
PORT TOWNSEND, WASHINGTON 98368 RECEIPT NO. 9,/,,,- .z.
BUILDER (206) 385-0722
SEWAGE DISPOSAL PERMIT DATE /Q —..2_-77
Submit in Duplicate
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Owner Address
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Directions for locating site D
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INSTALL NEW SYSTEM ❑ REPLACE SYSTEM ❑ PARTIAL REPAIR ICJ'' TANKJDRAINFIELD❑ _�
TYPE OF O
NO. OF SITE z
BUILDING pltpLLA BEDROOMS )._.- BASEMENT /16 SIZE
DRAW DETAILED PLOT PLAN BELOW. STUB OUT PLUMBING ABOVE FOUNDATION FOOTING 03 0
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SOIL LOGS o --I
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Dig two holes per site. (min.) ( 7)/ 0 z
4' deep -2' dia. -50' apart & flag APPLICANT X rr t 714,--C ; ,, o m
ANY CHANGE IN BUILDING OR SEWAGE DISPOSAL PLANS (INCLUDING PLUMBING STUBOUT n .._._cz-
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LOCATION) AND/OR LOCATION OF HOUSE OR DRAINFIELD INVALIQA ES THIS PERMIT UNLESS
PRIOR APPROVAL IS OBTAINED Pik' . . s , p „ I
Drainfield Length /Cc . Width
Depth'
De th ;1-4,.5 # Lines _-- Tank Si ze Gal. D COMMENTS: } rot f ( ) plit ; �� , , cPARTMENTS)d-3k Tut° 'tip . r -I
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17 I I oI31 / : t. l ~ ( .'L9- 0`\A ED ATE INSPECTED ( `-PAR
L/FINAL DATE
cI ogrtify that this system was installed in a manner approved by the Health Department.
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TALLER'S SIGNATURE DATE
DATE INSTALLED
JCHD/1-78
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FOR INFORMATIONAL PURPOSES ONLY-
Jefferson County does not attest to the accuracy of the data contained herein and makes no warranty with respect
o its correctness or validity. Data contained in this map is limited by the method and accuracy of its collection. Fri
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