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903 E. Caroline -ftyrlpic HEALTH DISTRICT Permit- NO'-,
Port Angeles, Wash. SEWAGE DISPOSAL PEM,1IT APPLICATION
Submit in Duplicate Builder- (Y W KA,,\-
Courthouse
Port Townsend, Wash. 7 f*- Sf Date
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OWNER d' ADDRESAIO,� qn,04,4S40-NE,
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DIRECTIONS FOR LOCATING SITE
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8� to Lfk"-c 2 VIA
APPLICATION IS HEREBY MADE TO: INSTALL NEW SYSTEM 44" EXISTING SYSTEM 4 --7;-
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)BEDROOMS BASEMENT SITE SIZE NAME OF INSTALLER
_M(i'
OV BUILDING NO.
Ad'
DRAINFIELD w=H:;o' DEPTH .2 #LINES SEPTIC TANK SIZE
DRAW A DETAILED PLOT PIAN BELOW, SEE INSTRUCTIONS. SOIL TYPE.
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ANY CHANGE IN BUILDING OR SEWAGE DISPOSAL PLANS, 1&-ATIONl ,,OR-,-SITE,,.,,.INVA-,L-IDATtS THIS".-,
PERMIT UNLESS PRIOR APPROVAL OBTAINED FROM THE HEJALT MENT.
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DATE OF INSTALLATION WAA I kx;&y^ SIGNATURE OF APPLICAjT=,4 1
An - r. - -J�
APPROVED DATE INSPECTED BY - DATE
SANITARIAN 'S COMMENTS :,,
I CERTIFY THAT THIS SYSTEM WAS INSTALLED IN THE MANNER APPROVED BY THE HEALTH
DEPARTMENT_ -DATE
INSTALLERS NAME
OHD 6-7$
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RUILL)MG PERMIT APPLICATION
•r • FVrT 70wnsMLr. {.dl^ 9.13611395 1310
�..,C nr•ia•rTrnl • Cnonry Cn„rtnous
Jr-lit–son Cnunry —.r
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I IILAIION. prup•onnir na^rr S VV SIDE O
G� h I ROAD ANC
ter. SW IROMINTERSECTION CY
—del
a� \��. � Sc
nxrfr Specific location or lanomarr r
1t\ I I GAL DESCRIPTION l
AL L
11. 1 YPE AND COST OF BUILDING
IN I.1 OF IMPROVEMENT
U New building
[] Addition
(] Alteration
Rrpa. replace e I
(] Wrecking
❑ Moving Ireloca`ion)
Foundation only
0i 1 U ! coy_
ROA: i f I E T
—74
Rd�{I 1Cr,
Ol IiiOCr 116 3,1
-- Secc r, 1Owntnrr.
i Srruon
Ian
OILVNERSHIP
Private Irndividual, corporation•
nonprofit institution, etc.!
❑ Public (Federal, State or local oo✓t-I
t (SST
•G
Cost of improvement... To be insialied bur nor included
in the above cost
a ElennoL------------------
b. Prurnoing------------------
c, Heating, air conditioning - - - - - -
d Otner !elevator, etc.). ........ .
• TOTAL COST OF IMPROVEMENT
BUILDING TYPE
�Smnlf Family
mull' -F amrly
number of unlit
Hotel, Motel, Dormitory
number of units
Mobile Home
�Yp Other — Specify
HOtb1
Lj
MOBI LITY
❑ New Countv Resident
Is this Structure to serve the re%,dentiai
or comrnerual needs 01 those employed
al eel her the U.S, Navy s Trrdenl Or
Indian Island Fac•1111es7
❑ YES ❑NO
USE
❑ Full-time Residence
❑ Second Home: RQcrea110n Cabin. et.
❑ Second Horne: Future conversion to
UBC OCCUPANCY GROUP:-- permanent residence
sed use of buildings, e.g., food
/Omit cents! Nonresidential — Desc, be in detail propo
processing plant, machine shop. laundry buildino at hospital, elementary
school, se condarV school, collece, parochial schoo', paik'no caraoe for
department store, rental office buddmg, othce building at rnovsiria plant.
If use of existing building is being chanoed, enter proposed use.
t
III. SELECTED CHARACTERISTICS OF BUILDING -
PRINCIPAL TYPE OF FRAME
Masonry (wall bearing)
[] Wood Frame
Sir uct Ural steel
ED Re, fol concrete
Q Oytcer — Specify
PRINCIPAL TYPE OF HEATING FUEL
Gas
Oil
)E leciricay
O Coat -
L]Other— Specify
DIMENSIONS 4
TYPE OF SEWAGE DISPOSAL
oPact S� 111
sss,,,......,,�(((Public or Private
p(1 Individual (septic tank. etc.)
TYPE OF WATER SUPPLYe)( (C�
� Public or private Company J
Individual (well• cistern)
TYPE OF FIREPLACE
•Number of Stories -------------
RESIDENTIAL
•Total square feet of floor area -
all floors, based on eaterror
f J y f
dimensions- - ----------------
ft.. - - - -
12
. Total land area, sq. - - - - -
C
mBER OF OFF-STREET
RKING SPACES
Enclosed ......................
--
-- ---------------
outdoors _------------------
RESIDENTIAL BUILDINGS ONLY Z
Number of bedrooms --------
TYPE
-------TYPE OF MECHANICAL Full .....
.--
Number o1
bathrooms Pan rat- . -
IV. IDENTIFICATION-
-- - Mailing Address — Number• street, city and State
Name
t � W O
11N.Y,
rate Lrcznse No.
\ a••.1. 1:10 --
A.a AseZ ( _
ZIP Code I Tet.
JI 1 C tVHLUA I JUN hLI"UtS 1
JEFFERSON COUNTY HEALTH DEPT.
Multi -Service Building
802 Sheridan Avenue
A&ort Townsend, Washington 98368
06) 385.0722
Applicant _ Charles Hawks _
Address: __30 S. 7th St.
Telephone: 385-0250
THIS REPORT DOES NOT CONSTITUIE APPROVAL OF A
BUILDING OR SEWAGE DISPOSAL PERMIT. THOSE
PERMITS SHALL BE GRANTED ONLY UPON APPLICATION
AND WILL BE REVIEWED IN ACCORDANCE WITH
CONDITIONS AND REGULATIONS EXISTING ON THE DATE
OF THE PERMIT APPLICATION. THIS REPORT IS NOT A
PERMIT APPLICATION.
Receipt No~1.233 ►
Fee: $45.00
Date: 11112/85
Sec. 16 _-___ Twn.._3Q ___ __-Rg. 1W
Lots 3, 4, 5, 6,_Hlock 12, Gise's Addition
Legal De5Cnp11en (Dry , elk. Lot)
Gle_ncove 30 S 7th St..
Duecuons lof Locating Site (Draw map on back).
Site Size 1.Q0'___x_200-_'_... _ _
Seller
Buyer
Evaluation of existin s stem re71970 for
I request This site evaluation for _ One single family residence or _.�—_�_-_____.gyp____. � __
replacing existing mobile with a new one.
INSTRUCTIONS: A minim"m ag Ilwo " 'no hols. .11 1 ... tmA 118-1 'loop I leall di -Mote.. and 1.0 too, ap.'Ii 94-41 J'a A-Q in The p'-poced
See attached instruction sheet.
A site evaluation of the above property was made on ___—____ November 14, _1985 by this department and the
property has been found:
,,ACCEPTABLE - Soil and a conditions are acceptab for installation of a sewag disposal system, as requc cd above, under
existing condi ns and regulations.
❑ CONDITION LY ACCEPTABLE - Soil an ite conditions are acceptab or installation of a sewage P's
system, as requeste
above, un existing conditions and reg tions, provided THE COND ONS SET OUT BELOW
ARE MET.
❑ UNACCEPTABLE - Soil and sitel-iw4pditions are unacceptable-tAL installation of a septic tanR�Gystem.
COMMENTS
This system was found to be functioning in a proper manner on this date. There
was no sign of drainfield failure. The septic tank was pumped on 11/15/85.
Re spec IIuIIy,
Randall M. Durant, R.S.
ENVIRONMENTAL HEALTH SPECIALIST