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Home My WebLink AboutSEP1975-00412ok E. Caroline OLYMPIC HEALTH DISTRICT Permit No. ?9 t Angeles SEWAGE DISPOSAL PERMIT APPLICATION Submit in Duplicatei Builder Co t Houde Po t Townsend Dat eld 7 V 3 ® �' - P//HOldrpi�� DI CTIONS FOR LOCATING Sm t-N� t TION IS Y MADE TO: INSTALL NEW SYg , AIR EXISTING SYST BUILDING N0. OF BEDROOMS BASEMNT SITE SIZA NAM OFINSTALLER EI,D LENGTH \ � i,IIDTS DEP 61 #LINES SEPTIC TANK SIZFFjDE ILED PLOT PLAN BELOW. SEE INSTRI7CTION6. SOIL TYPE A CHANGE IN BUIIDIt OR SLVAGE DISPOSAL PLANS, LOCATION OR SITE, IWALIDATES THIS PERMIT UNLESS PRIOR'APPROVAL OBTAINED FROM THE HCAiTH DEPARTMENT. DA OF INSTALLATION SIGNATURE OF APPLICANT00 DATE A r INSPECTED BY t6A,C �- D SANI ARIAN'S COAIMms: I C TIFY THAT THIS TE IN T ER APPROVED BY THE HEA D / 'INSTALLERS AMIE o� - y +4 EL COMMUNICABLE PUBLIC HEALTH HOME VITAL ENVIRONMENTAL DISEASE CONTROL NURSING NURSING STATISTICS HEALTH HEALTH EDUCATION JEFFERSON COUNTY HEALTH DEPARTMENT 802 SHERIDAN PORT TOWNSEND. WASH. 98388 (208)385-0722 Dear In accordance with the Federal Regulations for participation in the WIC Program is/are being removed from active participation in the Program at this time. A priority status was assigned to upon entrance to the Program, based upon category (pregnant woman, breast-feeding woman, post -partum woman, infant or child) and type of nutritional risk, according to a federal priority system. Since there are potential participants on the waiting list with a higher priority than yours/your child's, we are removing you/your child to make a space for one of them. We are very sorry to do this, but our goal is to reach those at highest nutritional risk. You/your child will be placed on the waiting list according to priority status, and will be placed back on the program should openings occur and you remain eligible for participation. If you feel this decision is unfair, you may request a fair hearing. If you have any questions, please don't hesitate to contact us. The WIC office number is (206) 385-0722. e�rnely, Mrs Phyllis Bee, WIC Director The WIC Program does not discriminate on the basis of race, color, creed, national origin, political beliefs, sex, age or handicap. If you feel you have been discriminated against, you should write to the Director, Supplemental Food Programs Division, Food and Nutrition Service, USDA, Washington, D.C. 20250. MUM t3U11 -NG ��ERMIT APPLICATION V r f n County Building DepartmenteP-O-'Box 1220®Porf Tounsend..WA 9836 H L FIC LOCATION' SITE ADDRESS ' POSTAL DISTRICT L--► /SUBDIVISION LEGAL DESCRIPTION LOT_-„,_BLOCKK D I V I S I ON — TAX NUMBER PARCEL NUMB ER % l4� / )o ��'�'`'I /'1 SECTION PLANNING AREA'_ SECTIONTOWNSHIP NORTH RANGE W!d PA BU 1 L NG I NFORMAT I SON BULDING TYPE SINGLE FAMILY ❑ MOBILE HOME ❑ MODULAR HOME ❑ DETACHED/ATTACHED GARAGE ❑ WOODSTOVE ❑ MULTI -FAMILY NUMBER OF UNITS COMMERCIAL INDUSTRIAL HOTEL/MOTEL/DORMITOR NUMBER OF UNITS-„ OTHER - SPECIFY BC OCCUPANCY GROUP TYPE OF IMPROVEMENT Cl oft NEW BUILDING AON �Y',,�'%ALTERLTERATION ❑ REPAIR REPLACEMENT ❑ WRECKING/DEMOLITION ❑ RELOCATION/MOVING MOBILE HOMES SIZE YEAR MA -- ESTIMATED COST OF IM PR3VEMF-N� ELECTED CHARACTERISTICS OF BUILDING RIIPLE TYPE OF FRAME WOOD FRAME MANUFACTURED STRUCTURAL STEEL ❑ REINFORCED CONCRETE ❑ MASONRY (WALL BEARING) ❑ OTHER - SQUARE FOOTAGE MAIN FLOOR 2ND FLOOR BASEMENT CARPORT GARAGE COMMERCIAL INDUSTRIAL/;— S 3 5 NDUSTRIAL S33 $16 07 $6 @ $s T .AL FAIR MARKET VALUE PRINCIPLE TYPE OF HEATING FUEL. ❑ ELECTRICITY ❑ COLLECTIVE SOLAR ❑ STOVE ❑ PASSIVE.SOLAR GAS ❑ GOAL ❑ OIL ❑ OTHER - SPECIFY DIMENSIONS NUMBER OF STORIES /-- TOTAL LAND AR DEPARTMENTAL REVIEW H ALTH DEPARTMENT TYPE OF EWAGE DISPOSAL NUMBER OF PROP�'SED IIF_' )UAJ �14;r ❑ P / L I C OF: PR 1 VAT£ NUMBER OF EXISTI1I!3 B£1 /"”` a! / - J�IVD I V I DUAL (SEPTIC) NUMBER OF FROPOSEDTe- BA' APPRO D DATE' � INDIVIDUAL WELL NUMBER OF EXISTING BA' PUD TYPE OF WATER SUPPLY Cl PUBLIC (NAME OF WATER SUPPLY% �..: AP ROVED DATE ❑ PR VAT£ (NAME OF WATER SUPPLY PL NNING DEPT, WI 'IN SHORELINE JURISDICTION YES NAME OF ADJACWATER BODY WA cs APPROVED DATE PU LIC WORKS DEPT APPROVED DATE IDE TIFICATION NAME ONT CH Cl NO / BANK HEIGHT SETBACK ROAD RIGHT-OF-WAY'WIDTH NAME OF PUBLIC ROAD NAME OF PRIVATE ROAD ------ ROAD ACCESS PERMIT REQUIRED ❑ YES ❑ IVO MAILING ADDRESS 1S -4 — 2I' P',I TEL HE OWNERIOF THIS BUILDING AND THE UNDERSIGNED AGREE TO CONFORM TO ALL APPLICABLE LAWS C E K NUMB6�ASH I GbfATURE IOF APPL 1 PROVED BUILOING OFFICIAL AP P I„ 1 CAT I Cite-DnT IE T /FOES / 7 J BASE FEE v BLDG SURCHARGE ENERGY SURCHARGE 81i NUMBER 1 "7.,r�� INSPECTION PLAN.CHECK J U. a v—" 1 TOTAL IND DATE I DATE ISSUED E1VEa JEFf /SJ"1,�U5 olt L� E ��SJ' Sipes L4 Screen: 01 REAL PROPERTY"Mode: INQUIRI Auto Roll: OFF Parcel # 000978900092 Geo Cd 282104207231 OLYMPUS BEACH TRACT 86 & T L TAX G FRTG * Taxpayer Cd SPEN 3850 SPENCER TRUSTEE, JOSEPH E. * Title Owner Tax Code 0231 Status TX TAXABLE Land Use Affidavit 69828 Vol/Page / C/U Code Legal Doc QCD 11/24/92 Amount Taxpayer SPEN3850 Search Ke JOSEPH E SPENCER TRUSTEE ELEANOR A SPENCER TRUSTEE SPENCER FAM REV LIV TRUST 371 VERNER AVE PORT LUDLOW WA 98365-9422 Nbad Cd 3310 TO Chg Dt 11/30/1992 T/P Chg Usr PM 1100 RES -SINGLE S/C Cd C OTH