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HomeMy WebLinkAboutEnvrionmental Health Subdivision Review ApplicationJefferson County Health DepartmentII LS CIE # 615 Sheridan Fee Check Port Townsend, WADate 98368 (360) 385-9444 OGT OTH JEFFERSON COUNTY ENVIRONMENTAL HEA TH M LAI (o _ ©OU FSS SUBDIVISION REVIEW APPLICATION SU &to — M0 Type (check): 4- Short Plat _ Long Plat \\_ Other (specify) Applicant Name: haul. + Gr^ SIr. aI0 e.N Address: igrLZ OA1C 3 Cd, QO�T 1�actl (.o clG. WD- 9'339 Telephone: 21%5- to3(o E-mail Address: Authorized Representative: Terr tA(! GIl-- ?.0 Goo tF'(,l t�-ev'f , wk A%36"b Address: Telephone: �jOl' li'43 E-mail Address: PROPERTY DESCRIPTION Legal Description: Section Township 29 ^( Range Parcel Number: °12t- OT3 - Oo5 Subdivision Name (it known): opavr\ 'ik to N*wA 5 T Ia+ # of lots 14- Average lot size b k- Minimum lot size 5. 4 0.O WATER SUPPLY SOURCE (check):Y- Individual Well _ Community Well Public (specify) P•V•7 Extension of existing system: P•J,- LawPA 4o Voo bR Previous Evaluation by Health Department _ Yes No Date of Evaluation: P­ "r.•,..,.. , ,., ­­,. _ NEED AT LEAST 4 SOIL TEST PITS PER LOT. ATTACH A COPY OF SOILS REPORT PREPARED BY A PROFESSIONAL ENGINEER OR A LICENSED SEPTIC DESIGNER, AND A PLOT PLAN SHOWING THE LOCATION OF THE TEST HOLES. This evaluation Adoes not constitute a guarantee of approval of an on-site sewage disposal permit. /0Aa//t � Date i a r of Applicant C:IDocumenls and satprgslmichlLocal SetlingslTemporary internet Fkn,s OLK41Subdivision Review Applicatlon.doc Rev