1995, 02-23 Permit App: 95000955 Residence PROJECT"NUMBER= 95000955 APPLICATION DATE= 02/23/95 PAGE= 01
****** THIS IS NOT A PERMIT ******
PENALTIES WILL BE ASSESSED FOR COMMENCING WORK WITHOUT A PERMIT
SITE STREET= 1216 S SKYLINE PL PARCEL#= 45193. 0716
ADDRESS= SPOKANE WA 99212
PERMIT USE= RESIDENCE / NAT GAS / HOT WATER HEAT
PLAT#= 000190 PLAT NAME= BEVERLY HILLS 1ST ADD.
BLOCK= 6 LOT= 16 ZONE= UR-3.5 DIST#= E
AREA= F/A= F WIDTH= DEPTH= R/W= 50
# OF BLDGS= 1 # DWELLINGS= 1 WATER DIST = EAST SPOKANE
OWNER= DAWSON, ROBERT PHONE= 509 994 0339
STREET= 811 S COWLEY ST #37
ADDRESS= SPOKANE WA 99202
CONTACT NAME= ROBERT DAWSON PHONE NUMBER= 509 994 0339
BUILDING SETBACKS: FRONT= 27 LEFT= 14 RIGHT= 16 REAR= 35
****************************** REVIEW INFORMATION *****************************
DEPARTMENT REVIEW REQUIREMENT
BUILDING PLAN REVIEW REQUIRED SSV a/Z4 9 C
COMMENTS: NO "' REB t .4 s• oN Fids• OccAtL, ¶ w1 .
BUILDING SETBACK REVIEW REQUIRED
APPROVAL: PER PLANNING DATE: 02/23/95
ENGINEER APPROACH/FLOOD PLAIN DRAINAGE
COMMENTS `' ���: k-,=td�" .' � �57� g•
' ' -I
j ClitMe 16/4 .f IMS Ze 'if j. ur..rea
� �► ► .oLow. ssp.HEAL ' P S EW NAI , W Sff WAER
1
COMMENTS: ' .� i � ` / _"/f i' ,f
PLANNING INADEQUATE FRONT YARD SETBACK
APPROVAL: AEE-99-94 DATE: 02/23/95
******************************* BUILDING PERMIT *******************************
CONTRACTOR= OWNER PHONE=
NEW= X REMODEL= ADDITION= CHANGE OF USE=
DWELL UNITS= 1 OCCUP. LD= BLDG HGT= 24 STORIES= 2
PRO —NUMBER= 95000955 APPLICATION DATE= 02/23/95 PAGE= 01
****** THIS IS NOT A PERMIT ******
PENALTIES WILL BE ASSESSED FOR COMMENCING WORK WITHOUT A PERMIT
SITE STREET= 1216 S SKYLINE PL PARCEL#= 45193. 0716
ADDRESS= SPOKANE WA 99212
PERMIT USE= RESIDENCE / NAT GAS / HOT WATER HEAT
PLAT#= 000190 PLAT NAME= BEVERLY HILLS 1ST ADD.
BLOCK= 6 LOT= 16 ZONE= UR-3. 5 DIST#= E
AREA= F/A= F WIDTH= DEPTH= R/W= 50
# OF BLDGS= 1 # DWELLINGS= 1 WATER DIST = EAST SPOKANE
OWNER= DAWSON, ROBERT PHONE= 509 994 0339
STREET= 811 S COWLEY ST #37
ADDRESS= SPOKANE WA 99202
CONTACT NAME= ROBERT DAWSON PHONE NUMBER= 509 994 0339
BUILDING SETBACKS: FRONT= 27 LEFT= 14 RIGHT= 16 REAR= 35
****************************** REVIEW INFORMATION *****************************
DEPARTMENT REVIEW REQUIREMENT
BUILDING PLAN REVIEW REQUIRED
COMMENTS:
BUILDING SETBACK REVIEW REQUIRED
APPROVAL: PER PLANNING DATE: 02/23/95
ENGINEER APPROACH/FLOOD PLAIN DRAINAGE
COMMENTS: $1/95.5:2-A/k.00 _024,-- { , ' .. , . /I ., ,kc 4 4�i
.., 040 8 , fi e°/ ' Ds 4-:. (4, .t Ructg b
4
s . 'fs $ s.
HEAL . ST NEW 4) - i L+NAL W7S4 WATER /,L Iper, ( 1 -2 --z3-55
COMMENTS: O
PLANNING INADEQUATE FRONT YARD SETBACK
APPROVAL: AEE-99-94 DATE: 02/23/95
******************************* BUILDING PERMIT *******************************
CONTRACTOR= OWNER PHONE=
NEW= X REMODEL= ADDITION= CHANGE OF USE=
DWELL UNITS= 1 OCCUP. LD= BLDG HGT= 24 STORIES= 2
4,10 N.
BLDG W X D = 76 X 30 SQ FT 3305 SPRINKLER= N
PROJECT NUMBER= 95000955 APPLICATION DATE= 02/23/95 PAGE= 02
REQ PARKING= #HANDICAP CRITICAL MAT= N
DESCRIPTION GROUP TYPE SQ FT VALUATION
BASEMENT U R-3 VN 785 8635 . 00
COV DECK R-3 VN 128 1152 . 00
DECK R-3 VN 64 384 . 00
GARAGE M-1 VN 672 8064 . 00
RESIDENCE R-3 VN 1320 72600. 00
2ND FLOOR R-3 VN 1200 66000 . 00
ITEM DESCRIPTION QUANTITY FEE AMOUNT
RESIDENTIAL VALUATION Y 839. 00
STATE SURCHARGE Y 4 .50
RADON MONITOR 1 12 .57
SALES TAX 1 1 . 01
RESIDENTIAL SURCHARGE Y 151. 02
******************************* MECHANICAL PERMIT *****************************
CONTRACTOR= OWNER PHONE=
ITEM DESCRIPTION QUANTITY FEE AMOUNT
BOILER/REFER 101-500M BTU 1 20 . 00
GAS LOG OR GAS INSERT 1 10 . 00
RANGE 1 10 . 00
CLOTHES DRYER 1 10 . 00
GAS WATER HEATER 1 10 . 00
GAS PIPING 6 6. 00
VENTILATING FANS 6 60 . 00
HEAT PUMP OR A/C 0-5 TONS 1 12 . 00
***************************** PLUMBING PERMIT ******************************
CONTRACTOR= OWNER PHONE=
ITEM DESCRIPTION QUANTITY FEE AMOUNT
TOILETS/BIDETS 4 24 . 00
TUBS 2 12 . 00
SHOWERS 1 6. 00
SINKS 6 36. 00
DISH WASHERS 1 6. 00
CLOTHES WASHER 1 6. 00
WATER USING DEVICES 3 18 . 00
PERMIT TYPE FEE AMOUNT AMOUNT PAID AMOUNT OWING
BUILDING PERMIT 1008 . 10 .00 1008 . 10
MECHANICAL PRMT 138 . 00 . 00 138 . 00
•
PROJECT NUMBER= 95000955 APPLICATION DATE= 02/23/95 PAGE= 03
PERMIT TYPE FEE AMOUNT AMOUNT PAID AMOUNT OWING
PLUMBING PERMIT 108 . 00 . 00 108 . 00
1254 . 10 . 00 1254 . 10
*******************************************************************************
* PLAT NOTE: TOPIC = CONDITIONS DEPT = BUILDING
*******************************************************************************
LOTS 12 & 16 BLOCK 6 HAVE SPECIAL DRAINAGE REQUIREMENTS
PLEASE REFER TO ENGINEERS
PROCESSED BY: JOHN LARSON
PRINTED BY: JOHN LARSON
******************************** THANK YOU ************************************
APPLICATION INFORMATION
What is the JOB SITE address? ASSESSOR'S tax parcel number?
l a!C 5- S—x vas P4$4 45/93. r"›
Legal description as it appears on the property deed
R,c 7 ,r Ar,z 40/1)) 7-1 iil & r isr 5i.t a
OWNER or OCCUPANT Phone�l
Mailing address City,state Zip
sill 3 ? 1/..> 1--4,45i
Who should we contact regarding this project? Phone
What work is being done under this permit?
/vEw Si//---7 �n>>i>tv 5,� >=�
Lone Inspector district Property size Right of way width
a) d
H
Water district
CI a
a) a�
0
Building Building height #of stories
Contractor Dimensions TOTAL SQUARE FOOTAGE
WA State Contractor license# Main floor area Unfinished basement area
Mailing address 2nd floor area Finished basement area
Architect/Engineer Garage area Size of decks,etc.
What is the heat source? What is the cost of your project?
Manufactured Home Sign
Width: Length: What is the square footage of How high is the sign?
the sign face?
Year: Make:
Installer Contractor
Wa State Contractor license# Wa State Contractor license#
Mailing address Mailing address
Relocation Fire Safety
Previous address Fire Sprinkler _ Tent
Paint booth_ Fire Alarm Fireworks display
VALUE
Contractor Contractor
WA State Contractor license# WA State Contractor license#
Mailing address Mailing address
Fuel Storage Tanks Swimming Pool
(Circle one) Above-ground Underground Size/gallons Private
Contents of tank(s) Size/gallons
Public/semi-private
Contractor Contractor
Wa State Contractor license# WA State Contractor license#
Mailing address Mailing address
COMPLETE ALL APPLICABLE INFORMATION
Spokane County does not discriminate on the basis of disability in the admission to, or treatment or employment in, its programs or activities.
PLUMBING PERMIT APPLICATION
PROJECT ADDRESS: 2,/C. 5 _5Ir..7-1J, ,11-2-,1r--#'"
OWNER: /4,,(3-}, 2-2-7— -3- qy2,x---�„ ) PHONE: , yt _ p 3
MAILING ADDRESS: g'// SC6L.,.7i �-4.7 s�,Ski.,,,,) ) Ji;4 2 "T`Y 2,S7--
(street) (city/state) (zip)
CONTRACTOR: /7 ryn�--/--- LICENSE:
PHONE:
MAILING ADDRESS: 5- -7a
(street) (city/state) (zip)
PLUMBING FIXTURES #OF ietnn- COST
DESCRIPTION I DETAIL UNITS num we /UNIT souAI.s AMOUNT
B02 TOILETS WATER CLOSETS,BIDETS 4 x $6 = $
B03 URINALS - x $6 = $
1304 TUBS BATH,JACUZZI,SPA,GARDEN Z x $6 = $
B05 SHOWERS(per trap) BASE,STALL,ON-SITE BUILD I x $6 = $
1306 SINKS LAVSBASINS,BAR,FLOOR KITCHEN, x $6 = $
LAUNDRY,UTILITY,JANITOR,PHOTO,
X-RAY,FOOD(PREP/CULINARY/MEAT)
B07 DISHWASHER - I x $6 = $
B08 CLOTHES WASHER - / x $6 = $
B09 GARBAGE DISPOSAL/GRINDER - x $6 = $
B10 WATER SOFTENER - x $6 = $
B11 ELECTRIC HOT WATER TANKS (NOTE: if gas water tank,see mechanical) x $6 = $
B12 FLOOR DRAINS AREA,CASE,COIL,TRENCH,CONDENSATE x $6 = $
B13 ROOF DRAINS/OVERFLOW DRAINS(ea.) - x $6 = $
B14 FOUNTAINS,DRINKING - x $6 = $
1315 WATER PIPING/DRAIN-WASTE-VENT/ INSTALLATION.ALTERATION,REPAIR, x $6 = $
PLUMBING REVERSALS REVERSALS
B16 SEWAGE EJECTORS GRINDER,SUMP PUMP x $6 = $
B17 WATER USING DEVICES ICE AND/OR COFFEE MAKER, x $6 = $
HOSE BIB,STEAMER,PROOFER,
CARBONATOR,SWAMP COOLERS
1318 CROSS-CONNECTION DEVICES VACUUM BREAKER,CHECK VALVE, x $6 = $
AND R.P.B.P.D.FOR VATS SUMPS,
TANKS,BOILERS,&SPRINKLER SYSTEMS
B19 INTERCEPTORS GREASE TRAP.SAND TRAP, x $6 = $
CHEMICAL HOLDING TANK
1320 MEDICAL GAS(per outlet/bottle station) NITROUS.OXYGEN x $6 = $
1321 MISCELLANEOUS FIXTURES x $6 = $
NOTE: MINIMUM PERMIT FEE IS$35.00 Subtotal
PLUS: PROCESSING FEE $25.00
SIGNATURE:� ____ TOTAL PERMIT FEE DUE $
PLEASE MAKE CHECKS PAYABLE TO
Spokane County Division of Buildings SPOKANE COUNTY PERMIT CENTER
1026 W. Broadway Avenue • Spokane,WA 99260
Tcl.No. (509)456-3675 $ Fax No. (509)456-4703 *TDD No. (509) 324-3166
\MASTER\PLUMPERM.FIND
MECHANICAL PERMIT APPLICATION
PROJECT ADDRESS: j 2/G 5 3—y;,�2_)_,./.,), >i).1-.�Com'
OWNER: /. (PHONE:
MAILING ADDRESS: g// 5- �>�.)c.� ,7
3 5.1)2,s5- t�.49- `''�-2-,---->'____
(street) (city/state) (zip)
CONTRACTOR: ,.6 ! LICENSE:
PHONE:
MAILING ADDRESS: ,y _
(street) (city/state) (zip)
IDESCRIPTION OF WORK =or<100,000 # ssusn- COST -
I OF UNITS Is,.Ls,YI(UNIT Iao°"" AMOUNT
$12 s
B02' FUEL BURNING APPLIANCE $15 - s
B0.'3''FUEL BURNING APPLIANCE >100,000
B04<UNLISTED APPLIANCE(ADDITIONAL CHARGE) =or<400,000 = $50 - s
$100 - :
B05i UNLISIbD APPLIANCE(ADDITIONAL CHARGE) >400,000 x
B06USED APPLIANCE(Must meet WSEC's min.AFUE rating) =or<400.000 = $50 - s
$100 - s
(Must meet WSEC's min.AFUE rating) >400•�
B07 USED APPLIANCE $12 - :
B08 BOILER/REFRIGERATION 1-looM BTU
101-500M BTU I x $20 - s
1109.BOILER/REFRIGERATION $20 - s
B10` BOILER/REFRIGERATION 501-1.000M BTU
1,001-1,750M BTU x $35 - s
B]1 BOILER/REFRIGERATION $60 - s
B12^BOILER/REFRIGERATION +1,750M BTU x
•
B13.GAS LOG,GAS INSERT,AND/OR GAS FIREPLACE _ / $100 - :
/ x $10 - s
B14 RANGE
B15 DRYER / $10 - :
B16 FUEL BURNING WATER HEATER - s
B17 MISCELLANEOUS FUEL BURNING APPLIANCE - $10x $1 - f
B18 GAS PIPING(ea.outlet) Mr ,1/4 51—
- / $10 - :
B19 DUCT SYSTEMS - x $10 - s
B20 VENTILATING FANS
$12 - s
B21 AIR HANDLER(DOES NOT include duct systems) =or<10.000 CFM x $15 - s
B22 AIR HANDLER(DOES NOT include duct systems) >10,000CFM
B23 EVAPORATIVE COOLERS - x $10 - :
- $50 -
B24 TYPE I HOOD
B25 TYPE II HOOD - $10 - :
B26 HEAT PUMP/AIR CONDITIONER 0-5 TONS I x $12 - s
B27 AIR CONDITIONER
6-15 TONS x $20 - s
I32$ AIR CONDITIONER
16-30 TONS x $25 - s
B29 AIR CONDITIONER
31-50 TONS x $35 - s
B30 AIR CONDITIONER +50 TONS x $60 _ :
B31 LPG STORAGE TANK - - s
$10$25 - s
B32i WOOD OR PELLET STOVE/INSERT - '
NOTE:MINIMUM PERMIT FEE IS$35.00 Subtotal
PLUS: PROCESSING FEE $25.00
SIGNATURE: _...,,,/‹.----4_...,,,/‹.----4y f TOTAL PERMIT FEE DUE $
PLEASE MAKE CHECKS PAYABLE TO:
Spokane County Division of Buildings SPOKANE COUNTY PERMIT CENTER
1026 W.Broadway'Spokane,WA 99260
Tel.No. (509)456-3675 *Fax No. (509)456-4703 *TDD No. (509)324-3166
master\mechperm.hnd
•
9 •".i-: .
''4�lk' SPOKANE COUNTY`PLANNING` DEPARTMENT ,': ' `7
APPLICATION, FOR,',ADMINISTRATIVE.EXCEPTION
`1t I�`r, 1k.... a ,,
v,:ov,,t,; (OTHER THAN;:LACK.OF ,PUBLICC t STREET FRONTAGE) .
• ' 1 ' '! r• FILE NO • AE - _9J'
SGia,
' lA t GENERAL INFORMATION .:.?.:s.::.11:`., ;," '
4 A •t�tu 1 ,
',Name of applicant : R„gr r ±r ElAz4LSc AI Agent:.Y
Mailing address: 8ll 5 cvr_iit-VY F :
City.
1:5 Pott sK , 'State: j sl d 1 ,: %JP Code:. ' o )7.-D-2..
PHONE Home: 964 0339 Work: Sirr>7S'
If applicant is not owner of property,need written authorization for applicant to serve as agent.
Legal owner(s)'name: fl,Agyt'r .1' V.4 t r5e nJ ' Phone:
Authorized agent(s)' name: NlePhone:
Parcel No(s).: 9sj2 Range: q.t 93:�0 7t�. Section: '� Township: =
Legal description: ,y,ryr rg sttnr.tr G-
r3ysnLu .���' £tasr zr h)
kuGt3Iit Sx) s/tl Vpl.t1)✓ig Sow Pres,fur •
Current zoning: u •5' Comprehensiv- Plan:
Arterial...„.Plan;. PI .
Current use of parcel: �MCANT 11110 P4.etlr� v�s11 �71.
, l4S#r.. Lb7'
r',i` . .
Street Addtessiof Subject Parcel: 12.7-6S 5i '1J, ) PLAr-it-
; a .
B.' SPECIFIC INFORMATION ,
S. 1! '(!
k.
Administrative exception requested(describe in terms of standard from which seeking relief):
LI .57,6• 6-7.21.7---'4140'
Z.a a�ri t AulmrrYjsru y c:c)57sart] Ati.e d 'n E3r111H 14 G16 •12-5-CYViJ.Y..,2,)t7
a*elM7M111011EiVe .M'a INrorz. ./Dififfir767117"12P:ilia
' /
ApplicablefiLYMIND l--1,1,707M"
pter/section of Code: J4ttL.3 �Hrx1. Yozps •
Explain reason forrequest: ,s tar ma s a'Au.Y senotvr1? iv7 'J�-/ 195-61S .
-Pis C tt zssrr 5s/2s Sgr7t.ccte $Z&, rJr ornitsI SJPEApC A M s++tjC> -re tp,h11221.1tfr A
P1.,)•1_, _e_ermoA`Ao1 r tartii crr& lotts77A3l:. f ii?As ' 03 This MEZ -Mbbp•-13:IP z,g-r
AIN' 1Jllits tiAL_ cilii1Q_,4.Gr+•. _ • r. r i : _e •. vr• ap .• • P . -.. ' Al
ligap4JM. tH. :5iC'T.8tr-les. rtAz 5EuraG+z/vTf 'l='s L 4tiEA L2Nr?' r, Art l FrOYI 7n& A,6rxrar,
Attach site plan with proper dimensions end other supportive information. •
Page 1 of 2
•
I sweat;under penalty of.perjury,that; .(1),I am.tlkq owner, rrecord or,autho,rized agent for dre.proposeel sit (2)it-
not the owner;written permission qorn said pwneranthori 9.myactions on 11,1s/her behalf is attachett;:ind(3)•all
of the above responses and those on suppor g documents a. nadc truthfully and to the best of ini-kriONVIedga.
Name: (7,3_ 253- ____Oe2/,
- , --;L).) • 1,•, •
Signed: /./ Y-.11j g
S tate of Washington )
) ss:
County of Spokane )
e
On this da - • .11 , ...... -I before me .880"VI • — • ' • •
to me ,,,• • • - kr 41,-'‘, . al(s)descri in and who executed the within and foregoing instrument,and
ackn•• -.•1,-3i. . •e. ,••PA,ii -: ed the same as his/her/their free and voluntary act and deed,for the uses and
4 lo
p •o\ rOli 4,-:14:,41/4 ,fr. (
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G! N ,,.'• tolArill. c . seal this -A—I- • day of __„ ea.Airt , 19?X
cn . ; . / .- sir)
CP • . iintw or /
. .- ‘..4
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NO 6..1 •t .. .. lrfor the state of Washington,residing at . t4,11,. r , ,L..e..
wAc.. ‘' ,,.. ,,i. r
...
_---: My appointment expires " • e 1 9 6 913-
. .
PLANNING'DEPARTMENT -PERSON1 EL IADNI,...r.t. '711e No: AE‘F '-'9°).-...a6
THE PLANNING DEPARTMENT APPROVES/DFNLES TI-ILS rADMIN 'IL6C11YE.EXCEPTIONI,EQR .PROP.RTY
DESCRIBEDt,A401PURSUA/sIT TO THE ZONINg CODE OF SPOICANII COUNTY,SECTIONS 14.566.000 AND
14.506.020''','(...t- 4; 2.' A%
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THIS ADMINISTRATIVE EXCEPT19141.7 SUBJECT TO THE FOLLOWING CONDITIONS AND/OR S-iIPULATIONS:
1 , v
. .
, v
The applicant shall comply yiipi all Fquiremegts And regulations of the Zoning Code.
The applicant shall comply with all rtqilireinent's of the Spokane County Health District and/or Utilities
R
,
63 Department regarding wastewater disposal and on-site water or public water systems. li
The applicant shall comply with the follicwing additional COnditions:t1;',
- •-.•• .• ) ;,, •:d.> . ,01 L'1 II. 1
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, .4 , . - Al.02i.itii fit sil i . 414 ' ..1(1 4 /./ , / ,..it _ _, _Aliii isi„.
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111:67:411411-v417411NEYIT1741111girlialliffailffatC liniffrigIV/11fliiMi_lardr.M1Fi!".1 .
iYA1/01121:41.7KITOINVEMPilrhflattEif.07,4111111111110/1141111111107
- •' ,' ,'.,
4 ....i,,,,,‘• ,_ (,:c.n,; 1--. 1,, efir * . - — •.,, 1 - . ; .
THIS • 'I, u • •TIVE EX EPTION SHALL RUNWITEI THE LAND.
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TH,, 4,,,,•''‘,,'4,,,.,.,,,,,,',,,„,,,.,,,.,,Y.,4,..,•,i.,i
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CERTIFICATE MUST ACCOMPANY YOUR BUILD G;PERMITI_APPLICATIO, N,
IF APPLICABLE f41,t.''''' ''''' ' ,''' t:',11 r,, 4 \',`.4 , ),. ' ',, ih,..ii /
NOTE:THE APPLICANT OR AN INTERESTED PARTY MAY FILE AN APPEAL'WITHIN 20 CALENDAR DAYS OF'Il III
ABOVE DATE OF SIGNING. APPEAL MUST BE ACCOMPANIED BY A$100.00 FEE. APPEALS MAYBE FILED AT l'HE
SPOKANE COUNTY PLANNING DEPARTMENT,BROADWAY CENTRE BUILDING,NORT11)721,JEFFERSON STREET,
SPOKANE,WA 99260(Section 14Al2.041 of the Zoning Code of SpOktinWOiinCy) i';','",,,,‘„,,,,,. ,,t , ;'.• 1,; , ,,,', , . ':; ,,,„ ,i,'",',''', '
\.
SPOKANE COUNTY PLANNING DEPAT ''ENT,721 NORTH'JEFFERSON;SPOKANE,WA 992601' '•/•:''
39) 456-2205 ' , ' , , . . /
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SPECIFICATION3 �' �� py.•• 1PEpE
TYPE OF SEWAGE SYSTEM: r� t G� / tt �4.. C A�,
(>U !�L S--w CECPp4
LINEAL OR SQUARE, FOOTAGE: -
TRENCfI WIDTH: tiro _._ ._'(__L__--__-
----
�� 15 ;.. 1 F J1-LiRg s \ 00;
DEPTH FROM ORIGINAL GROUND SURFACE TO BOTTOM
OF SEWAGE SYSTEM: p(4(//4 ..\
OTHER: X/ /Ncf/ '-/4-6t/ j03 62 Sc j '! ✓ /���ric�
PUG ist-ciF 4-i/ .5 c41:1) f'a/cr.� r,pc. /o
SIGNATURE `` .�� StR.41G QRS!6 1 Q/cc ti l'''`"
G DATE:2'� Vit `
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,1 • .a-Q`OKAN.0, WA . .99 Z./2
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PERMIT APPROVALS
Site Address or Legal Description of Property: S 1216 SKYLINE PLACE Appl.#: 95-00146
Parcel #: 45193.0716 Subdivision/Block/Lot:L16 B6 r Y HILLS 1ST
Critical Material User: DYes ONo Segregation Date:
CM Agreement Received-date: 100-foot setback required: DYes ONo
Sewage Maintenance Agreement Required: DYes ONo Easement required: DYes ONo
I DASADSCHD Density Requirements: DYes DNo Easement received - date:
Method I 0 Method 2 0
l Area of Special Concern: DYes DNo ID#:
1 Other Agency Approval/Date: (i.e., Engineers, Utilities, TESTHOLE APPROVAL SIGNATURE AND DATE:
Planning, DOH)
MINIMUM SPECIFICATIONS REQUIRED MINIMUM SPECIFICATIONS REQUIRED
I Flow rate: gal./day dosage vol. gal/cycle
DISPOSAL FACILITY:
I TREATMENT FACILITY: 0 Drainfield Size:- Flow Rate /(Soil loading rate
I OSeptic Tank Size: gals. No. gals./ft' X inches trench width) =
OGrease Trap Size gals. No. lin.feet ❑Cap Fill
1 ❑Pump Chamber Size: gals. No.
1 ❑Sand Filter Bed: Flow Rate / 1.2 gals.= ft.' 0 Leachbed: Flow rate / Soil loading
1 ❑Holding Tank: gals. No. rate gals./ft.' = sq.ft.
❑Building Sewer ❑Dist.Box
1 ❑Other: Alternative: ❑Mound OPressure Dist.SSAS
❑Sand Filter ❑Other:
See Alternative System Specs. Attached.
1 ••• MUST FOLLOW APPROVED PLOT PLAN ***
Other EH Program Approval and Date: DNA Application Approval Signature: Date:
❑FOOD DWATER REC:
❑SCHOOL DWATER:
❑OTHER: Approved Application Expires:
Double Plumbing Requested -Date: Building Department Release Date: Initials:
! ❑Required ❑Recommended DNA ❑See plot plan ��,,�� /
Installer/Designee: �f t,
Permit Issued Dater Expires: 73/1 Initials:
Installer Company: Multiple Unit Permit Expires: DNA
IDate:
! Installer Signature: „/, �! Final Inspection Signature:
NOTE: THIS IS A PERMIT ONLY WHEN THE APPROPRIATE SIGNATURE IS ENTERED
UNDER "APPLICATION APPROVAL SIGNATURE" AND "PERMIT ISSUED' DATE IS
COMPLETE.
REMARKS:
Page 2 - Permit