1993, 11-22 On-Site Sewage Systemt
APPLICATION ANp PEkMIT FOR ON-SITE SEWAGE SYSTEM
HEALTH DISTRICT (./2, j;', ,P
J /irr, (�%,� �J� APPLICATION NO. _% i!� -) i
ENVIRONMENTAL.HEALTH DIVISION �` T �7CENSUS TRACT / 1/ Z Z / .'.")
"-SPOKANE—COUNTY
WEST 1101 COLLEGE AVENUE l ; Q y DATE OF APPLICATION / •`L-'
- SPOKANE, WASHINGTON 99201-2095 (509)324-1560 INSPECTION RECORDING:324-1561
SITE ADDRESS OR LEGAL DESCRIPTION OF PROPER1Y: PROPERTY WITHIN:,K]
----
/I
/
/ () r
PSSA (OUT/INS.IDE ASA)
L/5 %?� (`�' [IASA)cGn'f s % if] WWMA (OUTSIDEPSSAASA,GSSA)
LEGAL QWNER OF PROPERTY: ADORES: , i PHONE: [] OUTSIDE ALL OF ABOVE
II " `,-, �j [ INSIDE ASA ONLY
PROPOSED USE Of "PROPERLY: ]SINGLE FA u Y RESIDENCE NUMBER OF BEDROOM "Z
.--
PROPOSED
OF S1RUCTURE: [] MOBILE HOME [RANCHER [] SPLIT ENTRY [] MULTI-LEVEL
[] MULTI -FAMILY COMPLEX: NO. UNITS _ NO. BEDROOMS/UNIT -
[] COMMERCIAL/INDUSTRIAL (DESCRIBE): #EMPLOYEES/DAY: #SEATS/CHAIRS FOR CLIENTS/CUSTOMERS:
77 -
IS
IS THIS PROPERTY LOCATED WITHIN A COMMUNITY PUBLIC SEWER SERVICE AREA? [] YES [] NO �`/
IF YES, NAME OF DISTRICT/SYSTEM: IS OLID AGREEMENT REQUIRED? 1(1] YES [1 NO
SEWAGE SYSTEM COMPONENTS: ``
'PROPOSED SYSTEM BY APPLICANT: + // ��jj REPLACEMENT/FAILURE: []YE'\[(jlO ALTERATION: []YES []NO
0] SEPTIC TANK(S) NO. _ I SIZE lf'?O( REASON: [] RELOCATE - CONFLICT
['] OTHER PRETREATMENT FACILITY [] SATURATION/SOG [] CHANGE OF USE
(SPECIFY) [] OTHER [] ADD-ON
1 DRAINFIELD [] LEACHBED
[1 BUILDING SEWER [] OTHER DISPOSAL; SPECIFY: WILL THIS RESULT IN AN INCREASED SEWAGE FLPW? []YES []NO
*1 NA -NEW SYSIEM
r '
,
WHAT 1S 1HE SOURCE OF WATER FOR THIS PROPERTY: PUBLIC/SHARED WATER SYSTEM; NAME: ----"/ .G ' 1 -Lt / •r ;'r ' /\ r' S -"
PRIVATE: [] WELL (1 SPRING [] LAKE [] 2929 APPLIES [] 2929 DOES NOT APPLY
PROPOSED PLOT PLAN IS 10 ACCOMPANY THIS APPLICATION, ALONG WIIH ANY OTHER PERTINENT INFORRA)ION, SUCH AS LEGAL UESCRIPIION OF
PROPERTY.
THIS APPLICATION AND PERMIT APPROVAL IS CONTINGENT UPON MEETING REQUIREMENTS SET FORTH IN THE SPOKANE COUNTY HEALTH DISTRICT
RULES AND REGULATIONS FOR ON-SITE SEWAGE SYSTEMS. APPROVAL IS BASED ON THE ACCURACY OF 1HE INFORMATION SUPPLIED BY THE
APPLICANT. IF YOU ARE DISSATISFIED WITH THE DECISION OF THE HEALTH DISTRICT, YOU MAY APPEAL 10 THE HEALTH OFFICER WITHIN TEN
10) DAYS OF DENIAL OF THIS APPLICATION (SEE APPEAL PROCEDURE OUTLINED IN THE REGULATIONS).
CONTACT. PERSON:, t pHONEi(S) , J $,IGNATURE OF,DWN R,OR A1UHQ.J1 ED .B,EIRES( VE:
/"T . l i 1'1 � t i t7 ' c r7 r r •. -
MAIL PER 1I AND CORRESeONDENCE 10:
INSPECTION CALL-IN.DAI:ES
TEST HOLE INSP!:':.) %
r''2' 7a
,: -Y
i,/`Y (.-.?•.
/
PARTIAL INSP.
FINAL INSP.
MINIMUM SYSTEM SPECIFICATIONS
FLOW RATE -f-' GAL/DAY DOSAGE VOL. GAL/CYCLE
BY DISTRICT: '
DISPOSAL FACILITY:` -
[] DRAINFIELD SIZE: FLOW RATE : [SOIL LOADING RATE
'
REINSPECTION
GALS./F12 x " TRENCH WID1H] = LINEAL FT.
[] GREASE TRAP SIZE: GALS. NO.
[] LEACHBED: FLOW RATE : SOIL LOADING RATE
0 PUMP CHAMBER SIZE: -c9•
"' GALS. NO. f
�'
EXPOSURE
[] SAND FILTER BEO: FLOW RATE
[] HOLDING TANK:
: 1.2 GALS = FT2
8
,�[I]ALTERNAIIVE: []MOUND [•]PRESS.DIST.SSAS []SAND FILTER
[]O11;ER (SPECIFY): :i/nit-1 /-,. 1 )''.,;,r^'`,'
•
fl BUILDING SEWER f1OTHER:
SEE ALTERNATIVE SYSTEM SPECS. ATTACHED
OTHER E.H. PROGRAM APPROVAL AND DATE:',
APPLICATION APPROVAL SIGNATOR At]D PATE: %,Jz. < "'t '-.
" / � .- / -;
FEE PAYMENTS:
APPLICATION
PERMIT
REINSPECTION
PLAN REVIEW
RENEWAL'
0
DATE
/y()
f"l. /— i <<v
REG.# _ PAD BY
1?tit7"C: If t.
;144 ,,,.
2929 REVIEW
CRITICAL MATERIAL USER: []YES
SEWAGE MAINTENANCE AGREEMENT
ASA/SCHD DENSITY REQUIREMENTS:[1YES
[°]NO ....,,�"..�� �,
REQUIRED?,[]YES ONO
[1N0
APPROVAL/DATE
�• • „��r.��
SEG. DATE: .' 100 -FOOT SETBACK REQUIRED? (IVES IS1N0
t
ir'--;•�
EASEMENT REQUIRED? (]YES,CINO
TEST HOLE APPROVAL SIGNATURE AND DATE: ,r, ,;, f, r
l •,:, r;,,,;. i,-, 1,4' i .,a/ai. • ;,",., ,r-'..- /';.t„ .. c,
OTHER AGENCY(i;e:., Utilities,Planning,00H)
, `!;
MINIMUM SYSTEM SPECIFICATIONS
FLOW RATE -f-' GAL/DAY DOSAGE VOL. GAL/CYCLE
BY DISTRICT: '
DISPOSAL FACILITY:` -
[] DRAINFIELD SIZE: FLOW RATE : [SOIL LOADING RATE
'
TREATMENT FACILITY:
Cl SEPTIC TANK SIZE:-.t",t"? GALS. NO. /f
GALS./F12 x " TRENCH WID1H] = LINEAL FT.
[] GREASE TRAP SIZE: GALS. NO.
[] LEACHBED: FLOW RATE : SOIL LOADING RATE
0 PUMP CHAMBER SIZE: -c9•
"' GALS. NO. f
�'
GALS./FT2 = $Q. FT.
[] SAND FILTER BEO: FLOW RATE
[] HOLDING TANK:
: 1.2 GALS = FT2
8
,�[I]ALTERNAIIVE: []MOUND [•]PRESS.DIST.SSAS []SAND FILTER
[]O11;ER (SPECIFY): :i/nit-1 /-,. 1 )''.,;,r^'`,'
GALS. NO.
fl BUILDING SEWER f1OTHER:
SEE ALTERNATIVE SYSTEM SPECS. ATTACHED
OTHER E.H. PROGRAM APPROVAL AND DATE:',
APPLICATION APPROVAL SIGNATOR At]D PATE: %,Jz. < "'t '-.
" / � .- / -;
i.
DOUBLE PLUMBING REQUESTED
[]REQUIRED (] RECOMMENDED
- DATE:
BUILDING CODE RELEASE DATE:. �' INITIALS:.--
`�
PERMIT ISSUED DATE: " / Z EXPIRES: / / INITIALS:
.////(';27';'`,/ / '.'/F / 1 4 --
'(I N/A fl SEE PLQT PLAN
ULID.10 APPL. DA1E1`./-Z`-`7.3',
[]208 REQUIREMENTS RCV'D
[1N/A [ 1 SEE PLOT PLAN
ULID RCV'D DATE: /' /6 %i to
INSTALLER: (PHONE NUMBER), (INSTALLER SIGNATURE)
FINAL INSPECTION SIGNAIU'E AND DATE:
REMARKS AND APPRQV.AL COND111ONS: (sep� reverse side also)";
2/► ?.i /`'i5_`� ,'I.lc,ii_<-
')Lv� Lir
Tr
SCHD-EHD-0532P(REVISED 5/92)
r sT 1 Intl,
FUTURE SEWER SERVICE AREA FORM: �FOLLOWUP DALE: ! /� T/''