1985, 08-27 Permit App: 0007124 MHlY
(THIS IS NOT A PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
COMPLETE IN INK
(Please return this original and your building plans to the Department of Building and Safety)
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Namett
Project Number —// 24.)
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Owner's LAST FIRST
A`tv.cl I— Marr 1a.
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DEPARTMENTAL REVIEW
Approved
Cond.
Approval
Hold
Environmental Health
❑ W 1101 College
Room 200
Permit Number
ler(n-1Z
`
Planning/Zoning
N. 721 Jefferson
Engineers
N. 811 Jefferson
Permit Number
Utilities
❑ N.811 Jefferson
Plan Review/Fire Prevention
❑ N. 811 Jefferson
Other (SEPA/Critical Material/etc.)
Fast Track/Special Inspection Information
Project Representative
Phone .
Address
I certify that I have examined this application and state that the information contained in it and submitted
by me or m ent is e, correct, legal, and bin
Owner's Signature Date CI 2:7(Y5
7
I
Show on Site Plan: Additional Information:
Lot Dimensions Landscaping
Existing Structures Drainage Plan
Proposed Improvements Hydrants
Structure Setbacks Topography
Easements Lighting
Septic System (s) _ • Signage
Water Lines Shorelines
Sewer Lines - Highwater Mark
Fences, Wells
Driveway(s)
Hight of Way Width(s)
Names of - -
Fronting Street ? , . i
Flanking7S$eet °I ;J.) sc_,i .•1
I
PERMIT NO
Name
Address of Proposed Site
Type of Use
SPOKANE COUNTY HEALTH DISTRICT .%
E. 0. PLOEGER, M. D., M.P.H., HEALTH OFFICER
N. 819 Jefferson Street
Spokane, Washington 99201(--�_ ^� %1�
DATE O( J /
06 q
No. A 10980
APPLICATION AOR ERMIT TO INSTALL OR RECONSTRUCT SEWAGE DISPOSAL FACILITIES
0
Address
/9//-2
Number of Bedroom d`
Water Supply
Septic tank capacity
Length of disposal field
P -073?_?
Is basement for building planned'
Building Capacity Camp Capacity
/
(City. Well, Spring). Drywell •
Other
gals Style of tank
Absorption Pits
Leach Bed
p) Show relative la tion-oL Proposed house. septic tank.
disposal. Held /jsll, �a age and other out buildings.
I Msk ote ny heal slope or s ,�// red ar any
oth an lopo:/; details,( a
q6.
Installer
Final Inspection Date
— —
I
,at
3r,
13` _- — —
ls'
A0'
30l
/0 -6 -lam/�—
Remarks
CONTRACTOR M
For Spokane County Health District