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903 East Caroline OLYMPIC HEALTH DISTRICT Permit No.�
Port Angeles Fee Paid 5
SEWAGE DISPOSAL PERMIT APPLICATION
Submit in Duplicate
C. 904s
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NAML�,�— . ig7;V ADDRESS ,/ s�qf g8136DATE c�i9 70
'LEGAL DESCRIPTION 714X 4r/8'�G� PHONE
�y�jDIRECTIONS!
FO�R� LOCATING SITE ,0t0# 0,o ���i! ®.� �'y�' /f&'* -1 44 �vo�if�.ank-
, I dPAd % ®moi �Ifr /Y �1 �Yli� �YW� IlilIWYI�rIiYLYYIISII. fi�.��ll��i - - -��
LJ /' ��—� "a., ///1" A~
APPLICATION IS HEREBY MADE TO: INSTALL NEW SYSTEM REPAIR EXISTING SYSTEM
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�
r—lyPE OF BUILDING NO. OF BEDROOMS BASEMENT SITE?a NAME OF INSTALLER
ON THE REVERSE SIDE, DRAW A DETAILED PLOT PLAN GIVING THE FOLLOWING INFORMATIOT•
1. Property lines 7. Driveways, patios,, carport, -etc.
a. 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 ���® gallow. 1"
5. Slope of land
6. Water lines & well(if 11. Length of proposed drainfield
applicable) 12. Depth to water if encountered.
PERCOLATION TEST RESULTS
Pere. No.
Fero. No.
Pero. No.
. Cyyk,ulzmere uired to Percolation rate
of hole seep last 6 in., (divide time by Q
1
2
-Type of soil
pRAINFIELD LENGTH_ WIDTHDEPTH NO. OF LINES
IT IS HEREBY AGREED THAT THE PROPOSED INSTALLA N WILL BE MADE IN THE MANNER
SS DESIGNED AND APPROVED ON THIS AiPPLICATION.
Signature of Applicant
APPROX. DATE OF INSTALLATION
SANITARIAN IS COMMEte.-" - -
_
a �Z�Ot�G7fir. ,G ,•.'
r4� Z11
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PLAN APPROVED i!�' �f DISAPPROVED DATEZ
DATE INSPECTED t
SANITARIAN A?
St?
REMARKS 411
QA
5-68
903 East Caroline OLYMPIC HEALTH DISTRICT
Port Angeles
Court House
Port Townsend
i BUILDING SITE INSPECTION APPLICATION
,1, Sub it, in Duplicate �i¢Trlt�
OWNER.4*/. l7 A% �T/i ADDRESS r&./ DATE y. 71P
LEGAL DESCRIPTION /%�a`1
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e ..
P .JRECTIONS
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FOR LOCATING SITE/ O&M& --rOy;W ®N COMM- smi, fe✓sr9
SA
AN APPLICATION IS HEREBY MADE FOR APPROVAL OF THE ABOVE LOCATION FOR A
STRUCTURE WHICH WILL BE SERVED BY AN INDIVIDUAL SEWAGE DISPOSAL SYSTEM.
kESIDENCE COMMERCIAL BUILDING OTHER
NO. BEDROOMS � BASEMENT�i1® SITE SIZE SOURCE OF WATER
�YPE OF SOIL �*-0Y 400* �.e� `DEPTH TO WATER TABLE / w
U:RAW A SKETCH in the space belowq indicating location
to other buildings, property lines$ welig,streams or o
Indicate proposed location of sewage disposal system,
VfYGi�7-
Date
Approved*
Inspection_®�
Disapproved
See reverse side for remarks.
of building in relation
ther bodies of water.
THIS IS NOT AN APPLICATION FOR A SEWAGE DISPOSAL PERMIT. A SEPARATE PERMIT IS
NECESSARY PRIOR TO THE INSTALLATION OF A SEPTIC TANK AND DRAINFIELD.
ROUTING SLIP -_MEMO
OLYMPIC HEALTH DISTRICT Port Angeles, Wash. 983E
0. SUBJECT:
FROM: DATE:
1 -3.0 --lo
MESSAGE: � r
1,a 3
11.67 For: .....Inf, „� Action „Approval Comment Reply