1978, 03-02 App to Install of Reconstruct Sewage Disposal FacMailing
Address
OWNER
Mailing
Address
L
REINSPECTION FEE RECEIP'
Date
Transmittal No. Application No B 0 5 9 2 7 {
Phone
INSTALLER
INSTALLATION PERMIT RECEIPT
Phone
Date (�
Transmittal No. i 1plication No,B r 0 9 2 7
INSTALLER
Transmittal No
SPOKANE COUNTY HEALTH DISTRICT
W. 1101 College 456-2340
Spokane, Washington 99201
Date
APPLICATION T INSTALL OR REC•NSTRUCT SEWAGE DISPOSAL FACILITIES
(/// Mailing 3-3���'%✓(�f
- Address
Phone
Phone _✓t(/ ri! 3
U Of aF
Of Use 1—`2
Water Supply: Public (Name)
Replacement? Yes
Septic Tans( �1
Capacity (/C/
Gals
J
Application No B 0 5 9 2 7
Address/Legal
Description
No. of
/ BBeeeddr000mmss
Fill Approval Date
Length of // T
Dispersal Piping/ C/ Ft
Sewer
Basement? Yes No Discharge? Yes No
OR Private Source
Building Sewer Elev
Drywell? Yes
Ft. Below Finished Grade
Drywell
Capacity Gals
Other Flow/Day Gals -
Management No. Of No. Of
Systems? es No , Acres Dwelling Units
Mgt Name
' VAT _ I (/•
si Sari •
IN4 ^� it �.i. //������ .iwr��..��.�
ans
•r �/ ' joy •
RE
AR
APPLICAN
...i I
APPLICATION BY.
Appli ation: Approval,/Date
I Ilation Approved By
CHO-ENV-002 (Rev. 4/771
terall AddressMailing
7
Expiration Date
2/
Date
i
ne /
f- 7?- 7 r
2->" 75 z /714- '. "74,4
idettoll
pie,„ 1,-1 7 C
erfil -atilt 9-
4)1292$ 4;6 fet--r,
ges,Racie4,7
-_,
�10
erei
ri!