HomeMy WebLinkAboutSEP1974-00037r
903 E. Caroline
Port Angeles
Court House
Port Tosg
(7 kA
s P r1j 3
OLYMPIC HEALTH DISTRICT Permit No. Q
SViJAGE DISPOSAL PERMIT APPLICATION
Submit in.Du 1p icate Builder
143d�i✓L P. L Date
DIRECTIONS FOR LOCATING SITE���
APPLICATION IS HEREBY MADE TO: INSTALL NEW SYSTEM REPAIR EXISTING SYSTEM
Ad�i7�LDING NO. OF BEBROOMS BASEMENT SITE SIZ11 NAME OF INSTALLER
DRAINFIELD LENGTH�1,►IDTH�DEPTH Z �T #LINW_ / SEPTIC TANK SIZE 7 S
DRAW A DETAILED PLOT PLAN BELOW. SEE INSTRUCTIONS. SOIL TYPE .S`/% -W it
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ANY CHANGE IN BUILDING OR S17'AGE DISPOSAL PLANS, LOCATION OR SITE, INVALIDATES THIS
PERMIT UNLESS PPt-'R APPROVAL OBTAINED FROM THE HEALTH DEPARTMENT. s
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DATE OF INSTALLATION SIGNATURE OF APPLICANT-�
APPROVED ✓' .. DATE INSPECTED BY �� °� S
DATE
SANITAR NIS
I CERTIFY THAT THIS TSF ':' TSTALLED IN THE MANNER APPROVED BY THE
HEALTH DEAPRT E T J'1' i( __ n n mL'
.4HOOPING COUGH: ,
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8�.."'_DING'FR('IIT APPLICATION
Jefferson County
Building Departmenfi�'P-0. Box 1220�F�orfi Townsendr,WA 98368
----
SPECIFIC LOCATION.
LEGAL DESCRIPTION
PLANNING AREA._ -_.--
SITE ADDRESS,-.,
POSTAL DISTRICT
SUBDIVISIO
LOT____-__, BLOCI D VISI
PARCEL NUM ER -
SECTION TOWNSHIP
BUILDING INFORMATION
BUILDING TYPE
❑ NGLE FAMILY
Moo ILE HOME
❑ MODULAR HOME
❑ DETACHED/ATTACHED
GARAGE
❑ WOODSTOVE
❑ MULTI -FAMILY
NUMBER OF U N I T S�
❑ COMMERCIAL
❑ INDUSTRIAL
❑ HOTEL/MOTEL/DORMITOR
NUMBER OF UNITS--
0
NIf'S,__,,,..-
0 OTHER - SPECIFY
UBC OCCUPANCY GROUP__
TYP OF I MPROVE?iENT
NEW BUILDING
❑ ADDITION
❑ ALTERATION
❑ REPAIR
[] REPLACEMENT
❑ WRECKING/Dr4MOLITION
❑ RELOCATION/MOVIIIG
1,10131 LE 1-10?l4ES•
S I xE
YEAR
MAKE
ESTIMATED COST OF
IMPROVEMENTS
$
SELECTED CHARACTERISTICS OF BUILDING
PR I P[r 1 E TYPE OF HEATING FUEL
EA,EGTR I C I TY ❑ COLLECT 1 Vl SOLAR
C]WOODSTOVE E] PASSIVE SOLAR
❑ GAS ❑ COAL
❑ OIL ❑ OTHER - SPECIFY
TAX NUMB
1/4 SECTION
ORTH RANGE
SQUARE FOOTAGE
MAIN FLOOR —
ZND FLOOR
BASEMENT
CARPORT
GARAGE
COMMERCIAL ,,
INDUSTRIA
a $38 —
@ $16
a $6
q1 $8
OTAL FAIR MARKET VALUE
PRINCIPLE TYPE OF FRAME
❑ WO D FRAME
J ANUFAGTURED
❑ STRUCTURAL STEEL
❑ REINFORCED CONCRETE
❑ MASONRY (WALL. BEARING)
❑ OTHER -
DIMENSIONS
TOTAL LAND AR
NUMBER OF STORIES_--
DEPARTMENTAL REVIEW
_..-----------^-^""'_ UMBER OF PROPOSED BEI
}� �p TH.pEPARTMENT TYPE OF SEWAGE DISPOSAL iNitUp4BER OF EXISTING BEI
e¢ 6Y�c14,4 jr.•�►i s�yt ,L lRd✓ P BL [ C OR Pi. I VATE
11 �,A'ry ." d yJr,��e� IS St o"OI I i DUAL (SEPTIC) NUMBER OF PROPOSED BA
CIC.- to -2S'( NUMBER OF EXISTING BA
APPROVED DATE 1 r;D I V 1 DUAL WELL
r� 4
Vv1'V PUD TYPE OF WATER SUPPLY
❑ PUBL 1 C( ?3AAIE OF WATER SUPP
R I VATE ( NAME OF YYAT UPPLY
APPROVED DATE ISDICTION
PLANNING DEPT. WITHIN .� ELINE
❑ YES NAME JAGEfIT WATER BODY
APPROVED DATE
u BANK HE 1 GIIT gETBAC
PUBLIC WOR DEPT ROAD RIGHT-OF-WAY WIDTH
NAME OF PUBLIC ROAD
NAME OF PRIVATE ROAR
APPROVED DATE ROAD ACCESS PERMIT REQUIRED E_YES ❑ NO
IDENTIFICATION zIP TEL NO
MAILING , ADDRESS
N A M E _ y-•
CH
HE-OWHER OF THIS BUILDING
1
*APPROVEAPDyff
TO GONFO O
AND THE UNDERSIGNED AGREE HERICHCKE
APP 1CAT iON DATE REC �MIT
APPLICAOLM LAWS;
NUMBER----- CASH
FEES �
BASE FEE
INSPECTION
BLDG SURCHA
PLAN CHECKRGE
ENERGY SURCHARGE
TOTAL
REFUND
911 NUMBER
DATE D ;SUED
BUILDING OFFICIAL
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