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18901 OLYMPIC
VIEW DR
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CLAIM FOR DAMAGES r�f
t�TICE
EI110nds GO GBrk
Claim MUST be presented to the City Council and tiled with the City Clerk within 120 daymonds City Wrk
from the date of Accident or Accrual of Damages.
TO THE CITY COUNCIL OF THE CITY OF EDMONDS:
PLEASE TAKE NOTICE, THAT !i / ,
marr�ied�ve huabaad's name
WHO NOW RESIDES AT U-e et��
present
street, number and city
AND WHO FOR SIX MONTHS PRIOR TO DATE OF ACCIDENT HAS RESIDED AT �le —
(Give residence by street, number and city.
CLAMS DAMAGES of AND FR@f THE CITY OF ED01oNDS IN THE S17H OF $ �53 3 SSi W-r
arising out of the following circumstances: W- t tva-"
Describe Claim, giving
DATE and TIME injury or
damage occurred, PLACE
and full particulars.
Accurately locate and
describe defects caus-
ing injury or damage
and all acts of negli-
gence claimed.
Accurately describe
injuries or damage
November 2. 1983 Approx. 8PM
Puget Dr. at Mrox. 12th.
road construction, large unmarked
hole left in road
Hit hole with right wheels, front
and rear and under carriage
1977 Porsche
State of damage
clad. Itemize temize all a ao'� I I 7 '] PoYc h P
expenses and losses.
ice tct'fiL�c.yte d 1� 1 /�
(Claim nut be sworn to b claimant)
Sigaa" of claimant)
8U&SOM AND 8{fiiORN
before me this day of .19
Wo%ar.Y-ra0lac 1n ana DL
Pashiagtion, residing a
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PUBLIC WORKS c�►n+ �R �"� � ��
NOTICE Epp A%PMft
Claim MUST be presented to the City Council and filed with the City Clerk within 120 days
from the date of Accident or Accrual of Damages.
TO THE CITY COUNCIL OF THE CITY OF EDMONDS-
PLEASE TAKE NOTICE, THAT 2�tee----
if married, give husbands name
H80 NOW RESIDES ATr/o
rstate present actua;//addrq6s by street, number and city)
AND WH0 FOR SIX MONTHS PRIOR TO DATE OF ACCIDENT HAS RESIDED AT
Dive residence by street, number and city)
CLAIMS DAMAGES OF AND nOM THE CITY OF EDMONDS IN THE SUM OF 8 1 S. I S si le trlerheycfal
arising out of the following circumstances: Mme w t
Describe Claim, giving November 2, 1983 Approx. 8:30FM
DATE and TIME injury or
damage occurred, PLACE Puget Dt . at approx. 12th.
and still particulars. road contruction, loarge unmarked
Accurately locate and
describe defects caus-
ing injury or damage
and all acts of negli-
gence claimed.
Accurately describe
injuries or damage
State items of damage
claimed. Itemise all
expenses and losses.
(Claim must be sworn to by claimant)
hole left in road
Hit hole with right wheels, front
anti rear_
1980 Cadillac Seville
ignature of t
EUBSCM AND BWORN
4a
before me this day of ,19
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03. /. 03
File No. 01.1.12
Street File
November 7, 1983
MEMO FOR RECORD
I inspected a street cut made by Grade, Inc. at 12th &
Puget. When I inspected this cut, the cut was not
restored to the City of Edmonds Street Restoration
Policy.
The City of Edmonds Police reported to me that they
had in fact filled the hole in the street with gravel.
The police report indicated that three vehicles had
damaged wheels and tires due to not properly restoring
the street cut.
I feel the contractor is at fault for not properly
restoring the street cut.
BILL STROUD
Acting Street Division Supervisor
BS/ml
Attachments
P.S. Contractor had not taken out a Right -of -Way Construction
Permit and was notified on 11/9/83by Dan Smith to obtain one.
See attached Permit which was issued on the afternoon of 11/9/83.
R. March
RECEIVED
CLAM FOR DAMAGES f oV 7 1QR i RECEIVED
rwTlcE PUBLIC WORKS N 0 V 71983
Claim MUST be presented to the City Council and filed with the City Clerk within 120 days
from the date of Accident or Accrual of Damages. Edmonds City Clerk
TO THE CITY COUNCIL OF THE CITY OF EDMONDS:
PLEASE TAKE NOTICE, THAT A . Yy Gt, 1� p e h "t, e, V^
(if married, give husband's name)
WHO NOW RESIDES AT / p O / oZ s� �� v, A `/ i N. L-
l ` I. Ed n ci ci , W n
State present actual address by street, number and city
AND WHO FOR SIX MONTHS PRIOR TO DATE OF ACCIDENT HAS RESIDED AT 5 e�L Y11
Give residence by street, number and city
CLAIMS DAMAGES OF AND FROM THE CITY OF EDMONDS IN THE SUM, OF $ �Jf/117V
arising out of the following circumstaPcgs iy/Q�'-c1, / Y�e-3
Describe Claim, giving
DATE and TIME injury or
damage occurred, PLACE
and full particulars.
Accurately locate and
describe defects taus-
ing injury or damage
and all acts of negli-
gence claimed.
accurately describe
injuries or damage
O i� �d ►-r.v a's, �ZLF .v coo r 4e-,q L i✓i�ir6'r�✓
�F�YT 1✓%JE�FG 1 p,��✓ .C)i�/S.f'FiY�� Sivi-'
State items of damage
claimed. Itemize all
expenses and losses.
(Claim must be sworn to by claimant)
(SijrAature of Claimant
SUBSCRIBED AND SWORN TO
before me this day of
Notary Public in f r khe State ,of
Washington, residi
'PERFECTION
"SINCE1962
TIRE CO.
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YCAANF, WA E0202
M. gigs DIVISION
SPOBANE HA 99201
E. 10721 PRAGUE RT. S BOX NH
SPOKANE. WA UMCOEUR WALENE, 10 M14
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W. IBM LEWIS
11N COWNBIA CENTER BLVD. "12 LEE BLVD.
PO BANE, 224"1"
PASCO, WA 99101
BENNEWICR,WA9B221 MICNLAND, WA 95292
'.0512211201
foolM7Jpl
(M)112i2i1 ISO)946-41 it
"SERVICE - OUR MIDDLE NAME FOR OVER 50 YEARS"
OWNED AND OPERATED BY PERFECTION TIRE CO.
N0.90 00.100 NO. I9l_I
No. 120
205 LOGAN ST. W. 12M N.E. BEL - BED NO. 10202DOT" S.W.
2009 FAIRVIEW
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RENTON SWAS BELLEVUE 9B00F [VNNWOOD 99026
SEATTLE 99121
HOME PHONE -
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SUBTOTAL
MECH. LABOR
YES ❑ NO ❑ ' M1"I•v AVTMOR1S( r"E "FAIR LOT a "
WOIIA NE AONAFTF R
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CUSTOMER COPY CUSTOMER SIGNATUREPLEASE REMIT TO: P.O. BOX 3624 • SPCiKANE, WA 99220
N0. rir °y 7Q
EDMONDS POLICE DEPARTMENT
e EC —,
INVESTIGATION REPORT DATE - TIME REPORTED
"YPE OF OFFENSE TYPE OF OFFENSE WITH ARREST
i PATE • TIME OF ARREST
FILE NO.
p(WIPEN/S�E /AND/OR
LOCATION OF OFFENSE AND/OR ARREST
EVIDENCE NO.
',`ICTIM NO. i ILAST - FIRST - MIDDLE) FIRM NAME IF BUSINESS D.O.B. OCCUPATION
RACE _ SEX . AG
_.suer in,__Raymond _V D 7— 0_4 -_l7_
_.M
:'�.DDRESS OF VICTIM RES. PHONE
BUS. PHONE
6-1 40
.'CRSON REPORTING (LAST FIRST MIDDLE; D.O.B. ADDRESS
RES. PHONE
Victim
VITNESS NO. 1 (LAST • FIRST • MIDDLE) ADDRESS
RES. PHONE
>USPLGI INU. I tLAsi-r;rcat-MIUUL6) Auutttbb bCHOOL ATTEND
BOOKING OR WARRANT NO.
CHARGE AND/OR ORDINANCE —
FACE -SEX -AGE D-O-B HEIGHT WEIGHT BUILD COMPL. HAIR EYES OCCUPATION
I.:LOTHING TATTOOS. SCARS. MARKS. PECULIARITIES
(1) Identify additional victims. (10) For burglary and larceny (car prowl) reports describe entry where and how,
(2) Identify and/on describe additional witrwsses. and tools used.
(7) Identify and/or describe additional suspects. (11) Reconstruct Incident (offense and/or ormst).
(4) Describe property taken, showing serial numbers, identifying marks (12) Indicate time and location where victims and witnesses may be contacted
and value of each. later by follow-up Investigators.
(S) Describe vehicle used by suspect and disposition. (13) For juwnilels) placed In detention, indicate nome, address and phone of
(6) Describe physical evidence, where found, by whom and disposition. parents or guardian and how notified.
(7) Describe victim's iniurin and whore medical efom occurred. (14) list persons you require to be subpoenaed to court.
(8) Report all property damage —describe damage and indicate amount (IS) Indicate if you need a CCDR or ADR and on whom.
of loss. (16) Indicate arraignment recommendations if any.
(9) Describe premises —or vehicle of victim and where parked. (17) Officer opinion. (NOTE: DO NOT PUT OPINION WITHIN ITEM I1).
1IXO.K. TO DISCLOSE ❑ DO NOT DISCLOSE ❑ DISCLOSURE NOT MENTIONED
l Guerin, Donna L...09-09-20 W/F, 18901 Olympic View Dr, Edmonds,
776-1540
I
Blue 1977 Porsche 924CP, Wa Lic DPC656, vin #9247231282. Right rear rim
bent and tire blown. Right front rim bent. Approx loss, $500.
Gray 1980 Cadillac FLE 4 dr, Wa Lic UJS661, vin #65G99AE685913. Right
rear rim and cover bent. Tire possibly damaged. Right front tire possib
damaged. Approx loss, $500.
Both vehicles are registered to Guerin Mfg Co Inc, 6027 208th SW, Lynn-
wood.
City street. Hole in street. See attached diagram.
Victim #1 stated he waswestbound on Puget Drive in vehicle #1 when he
struck the above described hole.
Victim #2 stated she was in vehicle#2 following victim #1 westbound on
Puget Drive when she struck the same hole. Both victims arrived home to
observe the above damage to their vehicles. Cones were on the sidewalk.
Copy to Street Dept.,
INVESTIGATING OFFICER SERIAL UNIT ASSISTING OFFICER APPROVED ASSIGNED DISPOSITION STAFF CARDEC
O'Donnell #412 113
77 - EPD-10
•r-D ON®5 POLICE DEPARTMENT M. M. FOSTER, chef
250 • BT04 N.. EDMO147D5. WASHINGTON 96020 PHONE 775.2525
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EDMONDS POLICE DEPARTMENT
IEC
11-3-83 1015 hours
Schultz, Erich E. 5-17-57 731 Puget Lane .775-6051, bus# 771-4030
V/W Rabbit. light blue in color, WA license EYF 770, VIN 17A0771558
registered to above. Damage to right front rim, rim bent causing tire
to deflate. Possible damage to shack asorber on -the same side. Cost
to repair $150. approximately.
:j 'City street. Hole in street, see attached diagram.
- Victim,.Erich, advised that he was WB on.Puget Drive in above V/W at
approx 2005 hours when he struck the above described hole. Victim
pulled over to the B&M store and noticed the rim was bent. When victim
awoke this morning 10-3-83 noticed the tire was flat. Victim then came
to station to report the above listed damage.
aw I I
12 U71-
S Pe "mit" No: _EbMOND
I �P�PUBIIIIOVORKS DEPARTMENTlssueDate It 9
RIGHT = OF WAY CONSTRUCTION PERMIT
ri A:' *Address or vicinity of Construction • Permit Issued PIQ
Eh46p_ Lo i 1-, V.
AN"
.6 iji`fOwner: Type of Work to be Done: E N_'�4 I
Name
e rork in Connection it'h:
Mailing Address
Sub or Plat X Single Family
El Comml. / Ind. El Apt. Condo.
City- State.,, Zip Code 0 Pavement Cut: Yes 0 No
Contractor: PIWN' fzc_ia—xs
ifkk "AN Name
V n I?Sox
Mailr9 \
Address State License Number
c
�, CIP A City, F State, Zip Code Telephone Number
'
NOWORK TO BEGIN) PRIOR TO PERMIT ISSUANCE
� B. APPLICANT TO READ ,AND SIGN
JINDEMNITY:'Appliant'funderstands and by his signature to this application, agrees to hold the City of Edmonds harmless
'- from ,any. -injuries, damages,, or' claims of any kind or description whatsoeveii, foreseen or unforeseen, that may tie made
WW'1'..�;,,!,'I�ia"'g-'�ai"n's'tr'the-City:of-Edni6hds,17�6'r"an' y`of its cl'e'Viii mienis bi �miployees, including or not limited to the defense of-a�y legal
,`,;proceedings including defense costs, court costs, and attorney fees by reason of granting this permit.
-��!,'�Upon issuafice of this permit, the contractor is responsible for workmanship and m ierials for a period of one year
:46'116wing the finil inspection and acceptance of the restoration by the Engineering Division;-
a
Funds -held from the Security Deposit (estimated restoration fee) will be held until t inl street patch is comp eted, at
q I
i"which ume a debit or credit will be processed for issuance to the applicant.
%
fWork is to be inspected. Restoration to be in accordance with City Code. Traffic Control to be in accordance with Traffic
cnof City`Code. St'reei to be kept clean at all times. A 24 -hour' notice" is 'required for inspection by Engineering.
161t,7%7-jrp:,`extehsion 100. 953
I;Unde6tancl' that "this"-picirmit must be available at the job site for inspection purposes at all times.
Signature Date
•raOwner or Agent
49
,MUST,BE POSTED AT., THE JOB SITE FOR INSPECTION PURPOSES
:,�THISPERMIT,.
"CALL DIAL DIG PRIOR TO BEGINNING WORK
F1
jed-By.- Permit Fee: 030. 6 0
ri�e' Wifthoiized:1 Void 'At I' f' '!N.7-75-0 days Security Deposit: 0-10FOO
V Will I
7.3
'cial Conditipnsf.,ik
Re el tNo.:
gn
amendments Street Cut Dimensions
1 0 1 ti:
41
At i
NO WORK TO BEGIN PRIOR TO PERMIT ISSUANCE
,411;
Eng. Div.., DcCcmbcrJ978_
t:F ..�f i...r777J r..C4..�.,x •.. 77 "„ .e77 d ;'.;.'"''r ': 'Lt '," ,t t: <,�. :n .1 ....:'r.. ,, :i,�7w. 77 ,+,777777.0 .i
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A
G. •NAME AND ADDRESS OF AGENCY
COMPANIES AFFORDING COVERAGES
ALEXANDER & ALEXANDER, INC.
2001 - 6th Ave. , Suite 1100
COMPANY A
LETTER n
Westin Building
Seattle, WA 98121
COMPANY B
LETTER
NAME AND ADDRESS OF INSURED
II
COMPANY
LETTER
GRADE, INC.
i P.O. Box 231
ETTERNY
Woodinville, WA 98071
COMPANY
LETTER
This is to certity that policies of insurance listed below have been issued to the insured named above and are in force at this time. Notwithstanding any requirement, term or condition
of any contract or other document with respect to which this certificate may be issued or may pertain, the insurance afforded by the policies described herein is subject to all the
terms, exclusions and conditions of such policies.
•` COMPANY
POLICY
Limits of Liabilityin Thousands
OCCEACH URRENCE
AGGREGATE
j LETTER
TYPE OF INSURANCE
POLICY NUMBER
EXPIRATION DATE
li
GENERAL LIABILITY
® COMPREHENSIVE FORM
BODILY INJURY
S
J ,
COO
f C O O
J ,
I!, A
® PREMISES -OPERATIONS .
® EXPLOSION AND COLLAPSE
MP 004000
3- 2 2- 8 4
PROPERTY DAMAGE
S
250,
S
250,
n HAZARD
UNDERGROUND HAZARD
Bodily Injury
Only
I V' PRODUCTS/COMPLETED
.
w+ OPERATIONS HAZARD
BODILY INJURY AND
5JCONTRACTUAL INSURANCE
PROPERTY DAMAGE
$
j
B
BROAD FORM PROPERTY
DAMAGE
1013
3- 2 2- 8 4
COMBINED
INDEPENDENT CONTRACTORS
Property
Damage Only
PERSONAL INJURY
S 500,
PERSONAL INJURY
AUTOMOBILE LIABILITY
BODILY INJURY
S
COMPREHENSIVE FORM
(EACH PERSON)
BODILY INJURY
S
A
OWNED
MP 004000
3- 2 2- 8 4
(EACH ACCIDENT)
PROPERTY DAMAGE
$
�i
HIRED
BODILY INJURY AND
S
NON -OWNED
•
PROPERTY DAMAGE
500,
COMBINED
EXCESS LIABILITY
C
UMBRELLA FORM
UM 9 4 41 WA
3- 2 2- 8 4
BODILY INJURY AND
PROPERTY DAMAGE
$
S
OTHERTHAN UMBRELLA
1,000,
1,000,
FORM
COMBINED
WORKERS' COMPENSATION
srATuroRv
and
EMPLOYERS' LIABILITY
s
TEACH ACCIDENT I
OTHER
II
�M
him
l DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES
v
i
138mbzMani mom
RE: On -Site Improvements
for Lois Vinyard Short Plat, Edmonds,
` Washington
Cancellation: Should any of the above described policies be cancelled before the expiration date thereof, the issuing com-
10
pany will endeavor to mail
days written notice to the below named certificate holder, but failure to
mail such notice shall impose no obligation or liability of any kind upon the company.
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NAME AND ADDRESS OF CERTIFICATE HOLDER:
! LOIS VINYARD
DATE ISSUED: October 28 1983 ch
` 19515 - 94th Place
Edmonds, WA 98020`^,
West LE ANDER A E AND RA NC.
i
AUTHORIZED REPRESENTATIVE
ulie A. Mittelstaedt
�� ACORD 25 (1 .7 ))
a
PERFORMANCE BOND
n
KNOW ALL MEN THESE PRESENTS: That whereas LOIS VINYARD, has awarded
to _,,
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(Coractor heU�na�terdesilnate astie rin�cirpaT, 1a contract or
construction of "On -Site Improvements for Lois Vinyard Short Plat," which
contract consists of Accepted Bid and Agreement, as attached hereto and made a
part hereof, and whereas, said Principal is required under the terms of said
contract to furnish a bond for the faithful performance of said contract;
NOW, THEREFORE, we the Principal and U. S. FIDELITY AND GUARANTY .Q4FINY
a corporation, organized and existing under
and by virtue of 'the laws of thtate of Maryland and duly
authorized to do business in the State of Washington as surety, are held and
firmly hound unto LOIS VINYARD, f/de/a(dd'/i'1M041f/0f
in the Sum of THIRTY THOUSAND NINE HUNDRED FIF
ONE & N0/100 - * * o ars ($ 30,951.50 -' -'—T, Tawf6l
money of the 61 to tates for payment of which sum wellan(T truly- to he made,
we hind ourselves, our heirs, executors, administrators, successors and
assigns, jointly and severally, firmly by those presents.
THE CONDITION OF THIS OBLIGATION IS SUCH, that if the above -bounded
Principal, his or its heirs, exe actors, administrators, successors or assigns,
shall in all things stand to and abide by, and well and truly keep and perform
the covenants, conditions and agreements in the said contract, and shall
faithfully perform and fulfill all the undertakings, covenants, terms,
conditions and agreements of any and all duly authorized modifications of said
contract that may hereafter be made, at the time and in the manner therein
specified, and shall pay all laborers, mechanics, subcontractors and
materialmen, and all persons who shall supply such person or persons or
subcontractors, with provisions and supplies for the carrying on of such work,
on his or their part, and shall indemnify and save harmless LOIS VINYARD, and
shall further save harmless and indemnify said LOIS VINYARD, from any defect or
defects, in any of the workmanship or materials entering into any part of the
work or designated equipment covered by said contract, which shall develop or
be discovered within one (1) year after the final acceptance of such work, then
this obligation shall become null and void; otherwise it shall he and remain in
full force and effect; provided that the liability hereunder for defects in
materials and workmanship for a period of one (1) year after the acceptance of
the work shall not exceed the sum
of THREE THOUSAND NINETY FIVE AND 15/100 - -• _
Dollars(S ,095—i5 _ �. -Ten percent of contract sum
And the said surety, for value received, hereby further stipulates and
agrees that no change, extension of time, alteration or addition to the terms
of the contract or to the work to he performed thereunder or the specifications
accompanying the same shall in any way affect its obligation on this bond, and
it does hereby waive notice of any change, extension of time, alterations or
additions to the terms of the contract or the work or to the specifications,
provided that said changes, extensions, alterations and additions shall not
increase the surety obligations under this bond by more than 10 percent of the
contract price without written consent of the surety.
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PROVIDED, FURTHER, that no final settlement between the Owner and the
Contractor shall abridge the right of any beneficiary hereunder, whose claim
may be unsatisfied.
IN WITNESS WHEREOF, the said Principal and the said Surety have caused
this bond and four (4) counterparts t er-eof to be signed and sealed bay3 their
duly authorized officers this 28th daaj-of October 19
U. S. FIDELITY & GUARANTY COMPANY G E, C.
ure y� incipa
By ?j �t.�,,� 'p'�9 ,�R.. TWO WITNESSE /
Caro L. erriar
Its Attorney —in —fact
Address of local office and agent of
Surety Company is:
ALEXANDER & ALEXANDER, INC.
2001 Sixth Avenue, Seattle, WA 98121
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data/forms, Inc. EDMONDS, WA 123456789
CONFIRMATION
CITY OF, EDMONDS., FIORDER
CIVIC CENTErl - EDMONDS, WASHINGTON 98020 - (206) 775-2525
PURCHASE REQUEST INVENTORY REQUEST WORK REQUEST
SHIP TO
'.THIS NUMBER MUST APPEAR -
"ON.ALL INV6ldES,jk'f;;:4' PACKAGES, BILLS"OFIA'DING
AND CORRESPONDENCE.
V);1c.lard
19515 qy' pj,
PLEASE FURNISH THE FOLLOWING ITEMS:
i�L',
QUANTI
UNIT
B'_
IT , "
co§i� P".
�1* '. TOTAL` COST
ESTIMATED ; xws
SUBTOTAL
TAX
TOTAL AMOUNT
/7YEAEP BY-
A-tn��
APPRqpED Bf
RECEIVED BY:
;.CODE
PROJECTCT
. AMOUNT
AM SITI,
ESTIMATE--,:. L.�.IACIVA
2
5
6
7
61
9
10
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CITY OF EDMONDS
rat., ENGINEERING DEPARTMENT
250 Fifth Avenue North, Edmonds, Washington
SEPTIC TANK INSTALLATION PLAN
(Submit in "Triplicate)
ADDRESS OF PROPERTY .............. 890.1...D1. piC View .Dr_...._.............. Lot No ....................... Permit No .... .2.��?4..........
Owner... -Bob De- Long . ....... ..... ............... Address ...18993 Olympic View Dr. e Edmore PR 8-2D49
......... ..................•
Builder..... Same ..._.._.......... . _...... .... ..._.. Address............ Same- ..._:....--.......---.........------....... Phone.......Sam.........
llesigner..... •B.Leyri._=• Phone..P3...$-�10.1 . o...................._........ Address.. ...,-- k
Richmond Concrete 2o624 , L nwood Was 743-3223
Installer.._....- . ......... .... ..... - Address.. - --- - --... ... -S --- - -• ..... --- one ..............
I hereby certify the accompanying drawing is an accurate representation of the system installed at the listed
address. I also certify all recommendations and restrictions (concerning plumbing stub elevations, maintenance of
grades, fills, surface drains, etc.) listed by me on my sewage disposal system permit application dated................
..........................................have been complied with.
.............
�sfr%
Signature of Designer Date
TO BE FILLED IN BY CITY ENGINEER ONLY
Accepted ................ ... Date ...... l.y. ...
Not Accepted Date
....... ...... .
Signature of Sanitarian ....... ............. ........... ........ .......... ..................
........
Remarks:.G%�atcC�... ���,��,rt'w...c �it...... �,r�....
--------------------------------------------------------------------------------------------- ----------------------------•------------------....------------.....................-----------•. •--
INSTRUCTIONS: Use the reverse side of this form for the drawing. Use a scale which will permit the greatest
detail and still contain the entire site on one page.
ATTENTION HOME OWNER:
Your septic tank has limitations! It was designed and installed to care for an average -size family. Over-
loading the septic tank or disturbance of the drain -field may seriously impair satisfactory operation. Points to
remember:
1. Have your tank checked periodically to see if pumping is necessary (2%s-3 years).
2. Do not channel ground water, surface water, footing drains or downspouts into the tank or drainfield.
3. Do not excavate, fill, place a structure, driveway or. patio in, on, or over the drainfield.
4. Limit toilet fixture disposal to sanitary wastes and toilet tissue.
5. Detergents and bleaches used in normal household quantities will not Karin the action of the septic tank and
disposal field.
3' v.ldsr a As —Built Dos igner s
LonT 1% B. Lloyring
BOB DE LONG
Olympic View Dr. Bo®a Box 32
Vdnon;:o, ,� „ L rnssrtood, Wash.Tr. Al Bob Kolong's Segreg. y
Portion of .Tr. 75, Edmonds, Soaaiew
SNO. CO. WAS11i.
Installer
May NO Installer
Concrete
20624 Hrry 99
/01
D• &x o /V,45
Olympic View Or. ' Inv,
e �
d
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• r `�e
9=x4-x6=
i 30
Eleyring Surveynrs, Inc.
Lynn ood0 71ash. PR 8-3101
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HEALTH DISTRICT
DIVISION OF SANITATION
Washington
APPLICATION FOR A SEWAGE DISPOSAL SYSTEM PERMIT
(Submit 3 Copies)
Permit to be issued to:........ BOb DeLo_ng ________________
For installation at: (street address)--------------�I O /`.`'✓'�/ �. ..
Addition or Subdivision ...... Por.,.Tr,-__75_t___ .............. _.................. Lot................ Block ........ ........
Type of Building: New...... X... Existing.....--..... Single family residence..... X...._-. Number of bedrooms 2
Other: (specify type or use) --------- --- -------------------------- ------------------ ------------- ------------------------------------------
--------------------------------------
Builder.....Bob..UeLo.ncg----------------------------------------------------------Address--...18903 Olympic Ave. Edmonds, Wash.
M. B. Meyring P.O. Box 32, Lynnwood, Washington
Designer------------------------------......................... ............................. Address.----- ....................... ----------------........ ........................ .--
Soil Log Hole No. sandy_ ---loam
_......
Soil Log Hole No. 2. u .. 48" sandy Loa►n..
-------------------------------------------•-•----------------------------------------------------•----..................... --.... ........ ........... -... ---.............................. .........
Elevation of Water Table, if encountered. Distance from ground surface None
Corrections to control surface water if needed .......... One__________________ .................... __ ___.............................................
----------------------------------------------------------------------------------------------------- --------------------------- --------------------------------------------- -----------------------
Specify if any removing or grading of topsoil in field area..---- None
--------------------
----------•------•--
Percolation:
Test Hole No. 1 —Average Rate ... 7...._................................. (Fall in minutes/inch-bottom 6" test hole)
Test Hole No. 2 —Average Rate ... .......................................... .......... (Fall in minutes/inch-bottom 6" test hole)
Test Hole No. 3—Average Rate.-.7................................................ (Fall in minutes/inch-bottom 6" test hole)
Average percolation rate on which to base drain field design ----_----_.-.----__ Date Taken... �/1�71.6�
Septic tank requirements based on present rules and regulations:
Septic Tank Size.....-9Q.................gallons.
Amount of Square Feet of Disposal Field ......... 0............ ...........
Signature —Designer- ---- /sp--
Date---// --�........................
DO NOT WRITE BELOW THIS LIN o be c pleted by Issuing Agency)
Permit issued (date).............11 �31(Q.-.........................Permit Number... a G. ............ ------------•
Remarks: ........ ..This. --parcel- of land is within the Unit 4 sewer project (L.I.D. No. 15
...Construetxosn_.to... begin- in-_the__sprina or__summer---of..1967-,----............................... ----...----•----------
BROWN
A'ry dp6utiui, from this design
without cul,sijltation with the
desigaer wlill make acceptance
of the ir:stallation subject to
tlle dPscretiur; of ttre ,iesigner.
Septic Tank & Drainfield Design
tUii Dr LQLC,
Tr."A" hob Det.ovig's Se(ireg.
Portion of Tr. 75, rdmonds Snaview
Sno. gash.
Aovember 1966
900 (jal Septic Tank
300 sq. ft. drainfield area
36" tret.ch
100 ft. liv. ft. Q
�Y1
Owner:
Laub DeLong
10903 Olympic Ave,
Frimonds, Wash.
Designer:
►-'. C. P eyri►:g
P.O. Box 32
Lynnwood, Wash.
Dote: Distance `
from sharp bank to drainfield
to be mininnim of 15 ft.
Top floor : 131.0
C;smt .Vlou r: 12:3.0
Stub out : 122.0
D.,,. Ontlet:121.0 --� �•
'teyri nrj -n rveyo rs , 1110.
Lynnivood, ':'ash, t'it 0-3101