2004, 11-18 Request for Sewage Waiver ft is v ti`'`'/
On-Site Sewage Systems (Chapter 246-272 WAC al't'er �?�
'. Request for Waiver From State Regulationssteivti,m3IN
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ction I. (completed by applicant)
(1) kca '-vctl S. 1l 5e-lk 1101111011C(CO--- Local Health Department/District (2)
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dress: L (-
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Spokane Regional Health District
- � -- _ Environments Health Di-vision
Z 1(9 1101 W. College Ave., Suite 402
Telephone: (59 ) 7 2_6 - 6 (9 Ce _l Spokane; WA 99201-2095
Signature:
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Property ldentificatioll: (3)
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Section II. (completed by applicant)
WAC Number: (4) WAC Requirement: (5) Waiver Sought: (6)
246-272 G•cjSp J /0 se1b i Y 2 .-, Dicc�_`e' r.-.. -_ - �r_,t , 7 6�
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____
Subsection: �j) "��� ��
Justification(mi[igat%�^ ,�onrure.c to be nrovid d): (7)
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Section III. (completed by health officer)
Review Criteria: (8) Mitigation Measures(in addition to those proposed): (9)
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Comments/Conditions: (10) '
Type of Waiver: (11) ] Class A ] Class B }Class C—Request DOH review before granting? Yes No (
Neighbor Notification: (12) / - //
Required? Yes No If needed, are agreements, easements, etc.properly filed? Yes No
Section IV. ( (completed by health officer)
This Request For Waiver From State Regulations has been reviewed according to the provisions of Chapter 246-272 WAC On-Site
Sewage Systems. The review criteria applied,and the mitigation measures proposed and/or required,have been evaluated for their ability
to provide public alth protection at least equal to that provided by this chapter WAC.
] Denied ] Approved I.T. .i•ted—Subject to .ll .v - ts,conditions and requirements none in Sections El and Ill.
Local Health Officer (13) /a'-----' ', ' 1, / ,,S Date: 1 1 if 6
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11/30/2004 10:31 5093241567 jS)HD EHS PAGE 01/01
Fla .
/6,i, ,,-1 Appt.Time ______________...____._...____,.. r, .. ‘
STEEL STRUCTURES AMERICA, INC.
1 -800-833-9997 1 -
Name La 4\ - k .__Iv o..I.0 / w —
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Mailing Address 1.3(12,-7
City 5f01cke. State \j‘.101 Zip —SJu
Job Address __ _.___...__--_____ '4 _ , ._.____-- ---..___
City _State __— . i __ __...... _____110..-41._
County ._ Zip ___,,,_..__. Sidewall Gable
Telephone Home Work _--_-__ _.--rr.- Building Size ___-__._-.X --- x .....0 .
20' 30' 40' SQ' 70' 80'Q 60' 90
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\ (.I fes, °� 92Pr, ADDRESS 1 r2 . ��igh
q50' I ( ZONE tti-�. ,I) _
ROAD WIDTH 1
v ���'� FRONT i 1-(J Cr LANKING, , '�
1'. i COMMENTS r -
--- REVIEWED SY VAI , 4 ^i
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This site plan is being submitted for the purpose of
70 `T--,------�_ �_ obtaining a buil0,�ng permit and is a true and correct
A representation cif the proposal. AH known property
line/dimensio .curb lines.shunter**and easements
have • , r*�, ' eare d awetlands,
r bodies•je steep •' other -ritical areas.
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.-t i / Date: t 1 -34 -C,L , V
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90' (*i• C F-- - /� '
_ . .i'T..--J _;-.._. _-----— Scale. 3/4 10.
Customer Signature S ignature`'
NOU 30 2004 10:36 509324156? PAGE.01