1988, 05-20 Permit: 0880385 Sewage System APPLICATION AND PERMIT FOR ON SITE SEWAGE SYSTEM �� �
SPC'RANE COUNTY HEALTH DISTRICT APPLICATION NO.
ENVIRONMENTAL HEALTH DIVISION ` CENSUS TRACT
WEST 1101 COLLEGE AVENUE DATE OF APPLICATION __2,0
SPOKANE, WASHINGTON 99201-2095 (509)456-6040
SITE ADDRESS OR L GAL SCRIPT F PROPERTY: P PERTY WITHIN: 0( PSSA (OUT/INSIDE ASA)
/44//44
�j - X�� /S-// 13/[� ] WWMA (OUT/ DEIO ASA)
(7 r" T [] GSSA (OUTSIDE PSSA,ASA,GSSA)
LEGAL OWN F PROP DRESS: PH(ge/kj [] OUTSIDE ALL OF ABOVE (�
' /ae � /� [] INSIDE ASA ONLY CLOP: I`-� 1
PROPOSE USE OF PROPERTY: GLE-FAMILY RESIDENCE - NUM OF BEDROOMS .9....../.9....../TYNPE OF STRUCTURE: MOBILE HOME [] RANCHER [] SPLIT ENTRY [1 MULTI-LEVEL
[] MULTI-FAMILY COMPLEX: NO. UNITS NO. BEDROOMS/UNIT
f] COMMERCIAL/INDUSTRIAL (DESCRIBE): #EMPLOYEES/DAY: #SEATS/CHAIRS FOR CLIENTS/ USTOME' :
IS THIS PROPERTY LOCATED WITHIN A COMMUNITY PUBLIC SEWER SERVICE AREA? [] YES [] NO 0/
IF YES, NAME OF DISTRICT/SYSTEM: IS ULID AGREEMENT REQUI'ED. 1
SEWAGE SYSTEM COMPONENTS:OSED SYSTEM BY APPLICANT
'�
S
PROP �i REPLACEMENT/FAILURE: ,QQYES []NO ALTERATION: []YES []NO
SEPTIC TANK(S) NO. SIZE �/�Q[/ REASON: / `
[ OTHER PRETREATMENT FACILITY YES
SATURATION/SDG [] RELOCATE - CONFLICT
(, (SPECIFY) ,[' OTHER [] CHANGE OF USE
DRAINFIELD [] ADD-ON
[] BUILDING
[] BUILDING SEWER WILL THIS RESUreegi""
ANINCREASED SEWAGE FLOW? []YES >O
[] OTHER DISPOSAL FACILITY i
- (SPECIFY) �� �,
WHAT IS THE SOURCE OF WATER FOR THIS PROPERTY: PUBLIC/SHARED WATER SYSTEM; NAME:
PRIVATE: [1 WELL [1 SPRING fl LAKE (I OTHER:
PROPOSED PLOT PLAN IS TO ACCOMPANY THIS APPLICATION, ALONG WI1H ANY OTHER PERTINENT INFORMATION, SUCH AS LEGAL
DESCRIPTION OF PROPERTY.
THIS APPLICATION AND PERMIT APPROVAL IS CONTINGENT UPON MEETING REQUIREMENTS SET FORTH IN THE SPOKANE COUNTY HEALTH
DISTRICT RULES AND REGULATIONS FOR ON-SITE SEWAGE SYSTEMS. APPROVAL IS BASED ON THE ACCURACY OF THE INFORMATION
SUPPLIED BY THE APPLICANT. IF YOU ARE DISSATISFIED WITH THE DECISION OF THE HEALTH DISTRICT, YOU MAY APPEAL TO THE
HEALTH OFFICER WITHIN TEN (10 DAYS OF DENIAL OF THIS APPLICATION (SEE APPEAL PROCEDURE).
CONTACT PERSON.• / ?4•17'-- 1- 5
SIGNAT 1 I'NER R A OR 0 REP TATIVE(' PHONE: DATE:
MAIL PERMITD E P DENC 0:
IN PECTION CALL DATES FEE APPLICATIONS. AN. "JD OA E R[ .,� PAID :Y
TEST HOLE INS .;� 1
PARTIAL INSP. PERMIT OP 6- 2.6-• ' /V 1, A-i
FINAL INSP. REINSPECTION
REINSPECTION
RENEWAL PERMIT
SCHEDULE OF APPROVALS�
CRITICAL MATERIAL USER: []YES iii" - A z ams POST ON J`�.1
,�
ISEWAGE MAINTENANCE AGREEMENT REQUIRED? (]YES NO .k SE ' 1E: 100-FOOT SETBACK REQUIRED? (1Y£S rINO
ASA/SCHO DENSITY REQUIREMENTS (]YES RIND '''' .., EMEN1 REQUIRED? YES i Ns
OTHER AGENCY (i.e., DSHS, PLANNING, DOE)`•APP'I I, & DATE TE7 I EcJ#P• UG • ill/ AN DATE:
�- S?"
ifs -.' 'l
/7) MINIMUM SYSTEM SPECIFICATIONS BY DISTRICT:
FLOW RATE GAL/DAY DISPOSAL FACILITY:
T E TMENT FACILITY: !�c-x71 [] GRAINFIELD SIZE: FLOW RATE : [SOIL LOADING RATE
SEPTIC TANK SIZE: G ' L// GALS. NO. GALS./FT2 x " TRENCH WIDTH] LIF LFT.
EASE TRAP SIZE: GALS. NO. LEACHBED: FLOW R : SOIL LOADING RAIL /i`S
[] PUMP CHAMBER SIZE: GALS. NO. ALS./FT2 = en SQ. FT.
SAND FILTER BED: FLOW RATE : 1.2 GALS = FT2 [] ALTERNATIVE: [ MOUND [] PRESSURE DIST. BED
[] OTHER: [] OTHER (SPECIFY):
SEE AL ERNATIV ...SYSTEM SPECS. ATT CHED� t� `+r
OTHER E.H. PROGRAM APPROVAL AND DATE: di APf L T N P OV` L SI T tE AND DA
T f, BU DING C DE�( L ASE DA ������"'''' INITIALS:
(DOUBLE PLUMBING REQUESTED DA i/ ii',. _ T�
J] REQUIRED (l RECOMMENDED I N/A ( S E PLOT PLAN
T
(_),208 REQUIREMENTS RCV'D ULID TO APPL. GATE PERMIT ISSUEp ITE: E I S: a ilk BJ S:
N/A (I SEE PLOT PLAN ULID RCV'D DATE: ~ /'� ?/� 0 / / �:
INSTALLER: (PHONE NUMBER) (INSTALLER SIGNATURE) FINAL INSPECTION SIGNATURE AND DATE:
REMARKS ANO APPROV C► AITION �� .------ 40_
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SCHD-EHD-0532 (REVISED 3/88) FOLLOWUP DATE: