1993, 11-16 Permit App: 93011190 Sewer 699 -PI- 6 2O3 q35
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED .
( IF NOWN )
JOB ADDRESS: /J00.(:; PARCEL'<NUMBER:
CITY:a��,-!''f6L/4.i2 STATE: (i(/ ZIP CODE: ;99'19,/,r
OWNER NAME: � �` ADDRESS:
CITY: STATE: PHONE: }1/ D� P
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES
( CIRCLE 0
*IF PROPERTY OWNER 'INSTALLING SEWER , THEY MUST FIRST CONTACT THE UTILITIES
DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED..
CONTRACTOR: 144 ;5 CQ f1-5'+1,1<�'ibn ADDRESS: I e 1 l e, \I w `
CITY: N5FIOk.1112. STATE: vJA PHONE: SOq - c12.(, • €3 (64
�1Cf2o
STATE CONTRACTORS LICENSE NUMBER . . : N•S CON I->k 123 Kc
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES N0 ( CIRCLE ONE )
INTERIOR ALTERATION WORK BY . . : •
ADDRESS: PHONE:
CITY: STATE: ZIP CODE:
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING , SHOP, GARAGE , ETC
THAT WILL BE CONNECTED TO THE SEWER .
V
SEWER CONNECTION - # OF BUILDINGS X 50 .00 = C -
INTERIOR PLUMBING ALTERATIONS: it OF BUILDINGS X 35 .00 =
TOTAL PERMIT FEE DUE $ 5 J
APPLICANT
SIGNATURE Ki.` /77 X72)
SPOKANE COUNTY DEPARTMENT OF BUILDINGS
WEST 1026 BROADWAY AVENUE SPOKANE ,WA 99260 ( 509 )456-3675
On-site Sewage Disposal System Informational Review
NOTICE
The review by the various departments as provided for herein is solely for the purpose of advising the Spokane County Health
District of the subject property's compliance with various codes and regulations. The issuance of a permit by the Spokane County Health
District for the installation of an on-site sewage disposal system is not to be construed as a vesting of a right by the owner /
representative to obtain a building permit for this property. At the time that a building permit is applied for the subject property must
comply with all applicable federal,state or local laws,ordinances or regulations with the exception of those relating to the issuance of a
permit for the on-site sewage disposal system by the Spokane County Health District,pursuant to this form. Accordingly,although as of
the date of this document the subject property may meet certain state or local laws, ordinances or regulations, in the event such items
change between the date of this document and application for a building permit, the owner / representative will be responsible for
meeting such regulations in effect on the date ofthe application for/the building permit. / /--0 J l
Sea ^
Street Address: I O 0 v // s;x ill S71- e JT A-,'�A/4
Parcel Number: 1711.`7 5, 0/ 0 9 #f•--- 9 / Z- 0//1 D v e€ A D A e€ s
Legal Dcscrip1ion: </C S / / Z. Z Po 4 ct9 ti 74, / g'v..J/4, GeeocD' 74. //Q S-A...A),9;w
Yrs/✓ K r c� p/`i , / `� ,. i/ 5�. .c a, C cr c.z.? .r._ c G.,e ' t' Sb.a1NAP C.p/��tC
76u.e o.440,
Property Owner: !•r)./,i c.yK,.-. T ,+1 / u:. �+ f Phone:
Mailing Address: 2 /�° C4
t — �..� e j s, y a y--
.606
Signature: ./3" .�" � Date:
/5-
PLANNING DEPARTMENT ,O/Cj 195 3 a
61II /rsSl /n7bo,e,
Vt—Dedicatory language within plat
iveizetGLc _— Subject property is legally divided
Certificate of exemption required
{4 Use authorized under the Zoning Code
/IA-Setbacks meet Zoning Codes requirements
N4- Shorelines permit required
i)n Variance required for the following reason:
Other: ♦e, i !i. .� e.-, e4�_.,. d —% /
��
0L/1 5 w-e^- <✓•e4Kv/�'/�iY ,� / •
Reviewed by: Z 2e �Jf/Itiv,Lt Date: 2'—/9
`9
DIVISION OF ENGINEERING
Site drainage review required
e aintained county road
d 1V Approach permit required FILE
("Flood zone '
Variance requirements
( Other:
•
Reviewed by: \ /��'�_1.��_ /.1 ...A.: • Date: /
DIVISION OF BUILDINGS TRANSACTION/I: 1 't 5"1 (/()
The Division of Buildings has advised the property owner/representative that an in depth review may be necessary when a formal
building pennit apil' submitted.
Reviewed by: ,diffi_f i LIL •_ Date: 9�y /5
py
,Dq . o l o q - tts. l o // 6th /-vve
. oi I I - w. iaio9 (0vE