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Spokane County
DEPARTMENT OF BUILDING & SAFETY
West 1303 Broadway Avenue Spokane, WA 99260 (509) 456-3675
INFORMATION WORKSHEET
PARCEL NUMBER:
STREET ADDRESS: Imo'O R,l)— 5c2& S ( P (,U o eTict
CITY/STATE/ZIP: SPO { A-5b; j (A) A cl O( .Q(y
SUBDIVISION:
BLOCK: LOT: ZONE: DISTRICT:
LOT AREA: F/A: WIDTH: DEPTH: R/W:
# OF BUILDINGS: # OF DWELLINGS: WATER DISTRICT:
OWNER: TO( -\ 4 \o) t 1 C Q C r o l' PHONE: coo\ - op. - 1 (F
MAILING ADDRESS: N - Sd(D s�(P LJ 0Q, k s"
CITY/STATE/ZIP: 'P0A k) (E l ) ( I 2A cP
CONTACT: PHONE: - -
SETBACKS: - FRONT: LEFT: RIGHT: REAR:
PERMIT USE:
****************************************************************************
BUILDING INFORMATION
CONTRACTOR LICENSE NUMBER:
CONTRACTOR: PHONE: - -
MAILING ADDRESS:
ARCHITECT/ENGINEER: PHONE: - -
MAILING ADDRESS:
NEW: REMODEL: ADDITION: CHANGE OF USE:
DWELL UNITS: OCCUPANT LOAD: BUILDING HGT: STORIES:
BUILDING DIMENSIONS: X (WIDTH X DEPTH) SQ. FT. :
REQUIRED PARKING: # HANDICAP: SPRINKLERED: CRITICAL MATERIAL:
SPOKANE COUNTY HEALTH DEPARTMENT
ARTHUR E. LIEN, M.D.M.P.H., IleaIth Officer
;/ Division of Sanitation /J ✓�
`.t V� N. 819 Jefferson DATE
Vne. J-- f Spokane 1, Washington
1 kl
• PERMIT NO • N? 14562
APP CATION FOR PERMIT TOoipIS ALL OR,RECONSTRUCT SEWAGE r`PO AL FACILITIES
Address h. De No
Name �D � � � `� 8 6 X ���
,/ of Property
Address of Bedrooms c.?.)
Type of Use Ot er
Cam Capacity Other
Number of Bedrooms Building Capacityp
Is property below grade of streets or alleys? Are streets graded in?
Is basement for building plan d '3How much excavation of 1 proposed'
Water Supply
%I�i�sii"✓� v'e"`v� Y, Well, Spring). Diywell �� Ic- 14--x! " �^-
Septic tank capacity -Q ®42 gals. Style of tank
Length of disposal field i--o
Leaching ed Dist. Box
(1) Draw in property area to scale. i°
(2) Show relative location of: Proposed house, septic tank, ilk ,-----
disposal field, well, garage, and other out buildings.
(3) Make.note of any heavy slope or swampy area or any j �2 j .Q4 y wt.1L-
other important topographic details.
Date when test hole will be ready for
SIN
inspection
Date installation will be ready for final inspection (that is,
before backfilling)
SANITARIAN'S REPORT AND RECOMMENDATIONS:
Date of Inspection
.
„- SL SAGE
Topography ,WING
it,t LCCA'.'.. sr
Ground Water 3iE ! 1t ^-tF
IS NCI_ T - _ :b Perrthlation tests: Minutes
Soil Condition '- _- c .
Special Recommendations
r
Final Inspection Date —- --
Remarks -
' �j
i - 4
' �'n1 �..f..F —” RECOMMENDED PERMIT BE ---•--- - —'
CONTRACTOR
Sanitarian
(Form 346—HealthTu
—SM-2-SS) Yy
)
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