HomeMy WebLinkAboutSEP1995-00114 JEFFERSON COUNTY PERMIT CENTER FOR OFFICE USE
621 SHERIDAN SEPTIC PERMIT APPLICATt• ► ?, Date
PORT TOWNSEND WA 98368 L5 C `,�1 Fee $
(360) 379-4450 Receipt # //I 7565
Check #
# �ZS
JEFFERSON ON COUNTY
PROPERTY OWNER T,, T , lea deg,' PERMIT
MAILING ADDRESS J1 /o& E, h $><r tt
I/On c"o LI v, A / 694
PHONE Area Code ( 50 ) 65- - 377((
SYSTEM DESIGNER /V.,/ / /ern /err t for,mss' i✓
LEGAL DESCRIPTION: Section 26, Township 3 Range I/ PARCEL # S72/ Z6..1 0e)6.-
Subdivision Name A tt i?'c /( Gave Division Block Lot(s) E'
SITE LOCATION ii'-0rn P ✓`„s .e , , 0 ol rn C' 67/kJ 4 Tel" %i )e,; Ccr �ira/"rt
000 Ccrl pgc-t 7 /ylive -Io J�� 4,4,07 ,/te (ATTACH MAP)
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TYPE OF IMPROVEMENT: Residential Commercial 5<,z/c'!zo e. 7-re--r; f d0 4 ,4, in C;c,,d s% IC
TYPE OF WORK:
New Redesign X Upgrade Repair Partial: tank drainfield
To 4/ bed vbc w.
Number of Bedrooms 7 40,7441 --Br- irftgr'd Length ft.
Basement: yes no Trench/Bed Depth c/ in.
Site Size C--,3 Number of Lines
Previous evaluation: yes X no Tank sizes ../rcv i 75V gal.
Water Source: Private X Public Soil type 7 (ATTACH SOIL EVAL.)
Drainfield Width ft. friawit Application Rate ai& gal./sq.ft./day
TYPE OF SYSTEM Mociyd .575/rte
4#***iF***41FiFitiFiFiFiFiFlF****4*#♦*...#.F**....*..#**.*#.*...•*.#.***********•*#4*t*#**** l***
THE UNDERSIGNED ACKNOWLEDGES THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT AND THAT
FALSE INFORMATION WILL NEGATE AND INVALIDATE THE APPLICATION AND/OR THE SUBSEQUENT PERMIT.
THE PROPERTY OWNER WILL BE RESPONSIBLE FOR THE ACCURATE LOCATION OF ALL PROPERTY LINES.
Signature Aj Arp, J Date /-17-c&
FOR O FICCE USE ONLJ Pr�5 hv ��- 7-@-1 e J bo ?mm(eay(�
APPROVED PART AL INA
RENEWED RENEWED
Planning District V School District Fire District 3 Community Plan
H:\HOME\PLNCNTR\INFOHLTHIPERMIT.FRM Updated 1/95