07-101427 � ,a� ,, .
City of Federal Way Demolition Permit #• 07-101427-00-DE
Community Development Services •
P.O.Box 9718
Federal Way,WA 98063-9718
Ph:(253)835-2607 Fax:(253)835-�609 �_ � � F`-� Inspection Request Line: (253)835-3050
� �
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Project Name: CONNERS
Project Address: 2648 S STAR LAKE RD Parcel Number: 516000 0230
Project Description: Demolition of a 900 sq/ft double wide mobile home.To make room for new construction.
Owner Applicant Contractor
KASEY CONNERS KASEY CONNERS KASEY CONNERS
2648 S STAR LAKE RD 2648 S STAR LAKE RD 2648 S STAR LAKE RD
FEDERAL WAY WA 98003 FEDERAL WAY WA 98003 FEDERAL WAY WA 98003
Additional Permit'lnformation
CONDITIONS:
After final inspection is complete and approved,Please contact Kari Cimmer by e-mail at
Kari.Cimmer@ci.federal-way,wa.us to.receive a refund of cash bond.
PERMIT EXPIRE� W��fnesday, Mar�h �8, Zfl09
Permit Isse�ed on Mancl�y, Ma1'Ch 19, 20f�7 '
I hereby certify that the above information is correct and that the constructian on the above cfiescribed property and
the�c:upancy and the use will be in accordance with the laws, rules and regulations of the State of Washington-
. nd the City of Federal Way.
Owner or ageni: Date: l—I �
\
� � • THIS CARD IS TO�MAIN ON-SITE ' '
�t�►oF Community Developme�� Inspection Rec��s��
Federai Way IVR INSPECTION REQUEST PI��JNE # (253) 835-3050
PERMIT#: 07-101427-00-DE
Owner: KASEY CONNERS
Address: 2648 S STAR LAKE RD
FEDERAL WAY, WA 98003-6918
This card is part of your required inspection documents. Scheduled inspections may be failed if this card is not on-site. DO NOT LOSE THIS CARD.
Inspections are listed as close to sequential order as possible(read left to right,top to bottom). Please schedule inspections as appropriate. Work must not
be covered until it is approved. Check with your inspector if you are unsure about any of the inspections or the inspection sequence On-going inspections
are logged on the back of this card.
� Final-Building(4050)
Approved
By c_:— w Date6.�.
�a-�9- v-7, t o 1 �2'l���
� ����IV I � -�
2�
un� �iA� 1 9 2�07 .� '? - .� � � � Z.�
�'ede�ra�wa� PERMIT
� ss�a�s"'"'�'d,,,'�s�u�uros��F FED�FtA1.1NAY SF MF CO ME EL PL�E EN FP
PBDBRALrWAY,WA 98069-9718,a�j��DING DEg�ppLI CATI O N
?53-895-2607•FAX 253-835-?609
������—�-_�_�
wmui.dtvoifedemhimu.mm -f�'m'-`
T.he ollo is ired i ormatton-an tnco Iete a lication wtil not be acce ted Piease rint tegibi in{n or ty .
-• • • - •
SITE ADDRESS _��O� U �7 � ��CA_1 IC�I.�`l' j� SUITE/IINiIT�
ASSESSOR'3 TAX/PARCEL 1� ,� �� � � �- Q � � � LOT SIZE(s�
LEGAL DE3CRIPTION(e.g.Acme Estates,�t�;� r`Y�ra.r�, '� i����� ���,t�, ����' a �
(A���P�Ia�NI�am►desa+p�nl
'• • • •
TYPE OF PERMIT ❑BUII.DING . ❑ PLUMBIN(i ❑ MECHANICAL
�DEMOLITION O ELECTRICAL ❑ EN4INEERINQ ❑ FIRE PREVENTION SY3TEM
PROJECT DFSC ION(Provide defaifed description of work included on this nermit onlul
1�� C�`
,
� a�
, .
PROJECT NAME(Name of Business or Owner Last Name) _� �1 1, I�I' �
• • • - •
PROPERTY ME � PRIM�A^�RY�PHONE
OWNER C�I�J �Z�.tGI C 1 �
MAILINO ADDRESS C ,3TATE Zi
�� c� C�U3
CONTRACTOR p�NAME . MPUCANT NAME OFFICE PHONE
�✓ �,� c2a��2yt� -71 s3
MAILM DRESS CITY,9TATE,Z CELL PHONE
L�u�S 5� �, r� ��l Pr c, c2�e� 33� -��f 3`�
CTfY OF FEDERAL WAY BU3INES9 LICEN3E NUMBER EXPIRATION DA FAX NUMBER
' - - -B L ' � � ) -
CONTRACTORS REC3[3TRATION NUMBER(coP7 0[e�rd reqnised wlth eFch applleatlon) EXPIRATION DATB
` � �
i — — — — — — — — — — — —
APPLICANT �MPANY NAME CANT NAMB OFFICE PHONE.'
j �/�-"'� �, C.� ( Z�l�)Z.�'-�7�S 3
j MAILfNU ADDRE3S CITY,3TAT&, P CEI.L P H O N E'
! (' S-��7�35
j RELATION3HIP TO PROJECT FAX NUMB
! o Architect ❑:Tenant o Agent ❑ Other(DescribeJ ( � _
CONTACT ME � PRIMARY PHONE � E-MAIL ADDRE�
� � Zfl(� ' �-
' LExnER N�$
f �nS(1� C.p."�fYl
� MAILiNO ADDR&4S C(TY,3TAT&,Z[P PHONE
. / ` � _
I
l
� ► . : � . • ,
�
EXI3TING U3E PROP03ED IISE
' EXI3TING ASSES3ED/APPRAI3ED VALUE i$ VALUE OF PROPOSED WORK � •
i
SPRINKLERED BIIII.DIN4? d YES ❑ NO FIRE SUPPRESSION SYSTEM PROPOSED%REQUIRED? ❑ YES ❑ NO
� WATER BERVICE PROVIDER ❑ LAKEHAVEN O HIGHLINE O TACOMA ❑ PRIVATE(WELL)
SEWER SERVICE PROVIDER p LAKEHAVEN . ❑ HIGHI.INE ❑ PRNATE(SEPTIC�
•• • • -
AREA D RIPTION EXI3TffiG PROP03ED TOTAL
S .FT. S .FT. S .FT.
BASEMENT
FIRsr o�� .a.: ��c�
���__�
SECOND �
THIRD �.-
FOURTH
ADDITIONAL FLOORS(DESCRIBE)
DECK(COVERED7) ` �
�`
GARAGE ❑ CARPORT O
�
raorouo ror.u.
NUNIBER OF FLOORS
••NEWHOMES ONLI"'* NUM OF BEDROOMS ESTIMATED SELLING PRICE $
Indiaate numlier of each type of fueture to be installed or relocated as part of this project. Do not indude existing fixtures to remdin.
MECT�AIVICAL
Value of Mechanica!Work $ j
AIR HANDLING UNITS EVAP TIVE COOLERS (3A3 LO(3S REFRI(3.SY3TEM3
$$Q$ FAN3 ,>.'�— HOOD3(commeret�ry WOOD3TOVE$
BOILERS FIREPLACE 3ER'�f3�`� RANdES MISC(Describe)
COMPRESSORS � FURNACES ,��` 4A3 WATER HEATERS
DUCTS QA3 PIPE OUTL
PL ING �� � �
BATHTiJB3�or'n�n/se��comnol 3HOWERS �`� WATER CIASEI'S Ron�q MISC(Describe)
D[3HWA3HERS SINK3 DRINKINQ FOUNTAINS
(iA3 PIPE OUTLETS 3UMPS ` RAINWATER SY3T
WASHIN�MACHINES�/ URINAL3 H03E BIBBS
. LAV3(earh,00mswcq VACUUM BREAKER3 ELECTRIC WATER HEATERS
� •
I cert(jy under penaity of perJury that the ir{formatton furnished by nee is true ared correct to the 6eat of ireg knowiedge, aved further,that I
am arathorlsed by the owner oj the a6ow premises to perform ihe worlc for which the per►nt!application ts irtade. I further agne to hold
harmius the GYiy oj Fedsratl Way acs to any ciatm�inciudtrig costs, expenses, and attorneys'fees{rtcurred irt ihe tnvestigatton and dejense of
such ciaitn�,whtch may 6e rreade 6y ang psrson,tnciuding the understgned,and itlea agatnst tht Clty of Federal Way�but only where such ctaim
artses out of the nitance oj the city,inciuding ib ofjicers and empioyses,upon the accuracy of the i�}formation suppiied to the city as a part of
ihis appHcatton., '
NAME/TITLE DATE�� I `
i rn�i
RELATIONSHIP TO PROJ T Owner ❑Agent O Contractor ❑ Architect o Other
......_�.,.._,.
- - ---- - - ... .,.._ ,. .
,,. - °- •--''--'--
, �
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i •
' ' ' � • � •
RESIDENTIAL COMMERCIAL
' NEW RE3IDENTIAL SERVICE NEW COMMERCIAL/INDUSTRIAL SERVICE
❑ suingle Family Square Feet Seruice or Feeder Each Add'n
(Ayrst 1300 th-�107.50;Each addh S00 tY+-$34.50) ❑ 0 to 100 aznp $117.00 $71.50
❑ Detached outbuilding or garage 0 101.-200 amp 145.00 91.50
(Inspected with service) $45.50 ❑ 201-400 amp 272.00 107.50
❑ Detached outbuilding or garage ❑ 401-600 amp 317.00 127.00
(Inspected separately) $71.50 ❑ 601-800 amp 410.00 173.50 �
❑ 801 - 1000.amp 500.50 209.50
NEW MULTI-FAMILY(three units or more) ❑ Over 1000 amp 546.00 291.00
Seruice Feeder
0 Up to 200 amp $117.00 $34.50 ❑ Over 600 volts surcharge $91.50
0 201 -400 aznp 145:00 71.50 ❑ Mast or meter repair $99.00
❑ 401 -600 amp 198.50 99,00 �,TERED QOMMERCIAL/INDIISTRIAL
! � 601 -800 emp 254.00 136.00 "
❑ Over 800 emp 364.00 272.00 Seruice orFeeders
❑ 0 to 200 amp $117.00
ALTERED 8INC3LE/MULTI FAMII.Y ❑ 201 -600 amp 272.00
❑ 601 -.1000 emp 410.00
Sen�ice or Feeder ❑ over 1000 amp 456.50
❑ 0 to 200 amp $89.50
❑ 201 -800 emp 145.00 ❑ #oPcircuits to be added/altered
❑ ovei 600 amp 218.50 ' (1-5 circuita-$91.50;Add'n circuita,$7.00/ea)
� ❑ #of circuits to be added/altered COMMERCIAL/INDUSTRIAL PLAN RE�TIEW
(1-4 circuits-$71.50;Add'n circuita$7.00/ea) $91.50 plus 35%of Permit Fee
� ❑ Service- 1,000 amps or greater
❑ Mast or meter repair $53.50 ❑ Medical/Educational/Institutional Facility
MOBILE HOMES
❑ Service or feeder only $71.50 '
0 Senrice and feeder $117.00
't'EMPORARY SERVICE
MOBII.E HOME/RV PARK Restdential/Muitt-Famiiy $63.00
❑ #of seivice or feeders
([�rat servIce/feeder-$71.50;each add'n-$46.50) Commerciai/lndusMai Seru�ce or Feeder Ampaccity
❑ 0-100 amps $71.50
❑ 101-200 amps 91.50
❑ 201-400 amps 107.50
❑ 401-600 amps 145.00
❑ over 600 amps 157.Op
MISCELLANEOUS SERVICE/EQUIPMENT
0 #of Thermostats � ❑ #of Signs
(First-$53.50;add"n-$16.50/ea) (First sign-$53.50;addh sign.$25.00/ea)
❑ Low Voltage ❑ Swimming pool/hot tub................ $107..50
Square�'ent to be served by spstem(s) pncludea addidona!circuit,if iequind)
❑ Fire Alarm 3ystem ❑ Yard Pole meter loops..................... $71.50
0 3ecurity Alarm System ❑ Additional Plan Review $107.50/hour
� voice Cabling (for modified submittals)
❑ Data Cabling
� ❑ Automatioa Fee oa s�ll Permits .. $5.60
(Per Syatem(s) 1��2500 ft�-$63.00;
Each addh 2500 ft�-16:50)•Per WAC 296-46910(5�(bJ(i&ii)
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__� Puget Sound Clean Air ncy �
�7 2O9 ' 1904 3rd Ave Ste 105 .'f ;,�� I �' .�,
� Seattle WA 98101 -3317 '�`° '
p s s f e a n a i r,o r g 206.343.8800 • 1.800.552.3565 f8X ��� �='
` t;"`' 206.343.4073 N
�-� 1� ' Notice of Intent ���'° ���-�=
�;�„
Type or print Gea�1y
A.Pro'ect T e: 1. ❑ Friable Asbestos Removal 2. ❑ Friable Asbestos Removal&Demolirion 3. ❑ Demolirion Onl
B.Property Owner: �� �� �`� Phone: � �
M1{'�ing Address: Ci : � State Zip:
�,� �"� � �� l�W
C. Asbestos Contractor: ``�` `- ���.�� Owner/C ;C r j �
a
Mailing Address: Ph ne: ntractor
'' ��-S� Job No.:
Ci : State: Zi : Fa�c:
D. Sii e Address: City: t p Y�� � ZiA1��
-� a�, ��
Contact Person: Local Phone: - �^
E. Asbestos Survey or No. of Structures: Dat�of be to �ey: Was Friable Asbestos Identified? ❑Yes o
❑ Mat'1 Presumed
AHERA Building Inspector: Certification#: �Nas Nonfriable Asbestos Identified?OYes �,No
Ex .Date:
An AHE21 Survey is required bejore all demolition projects
F. Demolition Start Date:, ' � � No.of S ctures: 1. Training Fire(List Fire Dept.)
Information: 2. ❑ Ordered Demolition attach co of rder
Demolirion Insert demolition contractor�s maut„g address on vack. ' nonfriable asbestos be left in place during demo? Yes
Contractor:�-T Q N
G. Friable Asbestos Start Date: Complerion Date: Work Days: M T W Th F Sa Su
Pro'ect Information: Hours:
Total Qty.to be Removed: Linear Ft ` '`� -' " S uare Ft. Will all friable asbestos ❑Yes
�a t ` � materials be removed? ❑No
r ,,
H. Asbestos/Demolition Project Categories: �..;> Notification Period Project Demolition
��. {�a.
1. Single-Family Residence(owner-occupied): , A.Prior Norice Fee Surcharge
A. ❑ Asbestos Removal Project Only ��'�j' ��' B. 10 Days* A. $25
B.�, Demolirion Project(with or without asbestos removal project) B. $50
* Asbestos removal can be ' on notification;demolirion must wait 10 da s
Note: If the single family residence is owned by one family who has been or will be using the residence as their domicile,the above boxes 1A
or 1 B may be checked. If this is not an owner-occupied residence,one of the catego�ies listed below must be used instead.
A si le famil residence does not include rental pro erty, multi-family units,or an mixed-use buildin .
2. ❑ All Other Demolitions(with no Asbestos removal or Nonfriable Asbestos 10 Days $50
onl or less than lO linear feet and/or 48 s uare feet of friable Asbestos
Friable Asbestos Pro'ects other than Sin le Famil Residence : Asbestos Demo
3. ❑ >_ 10-259 linear feet and/or>_48- 159 s uare feet of asbestos Prior Notice 10 Days $50 $50
4. ❑ 260-9991inear feet and/or 160-4,999 s uare feet of asbestos 10 Days $200 $50
5. ❑ >1,000 linear feet and/or>5,000 s uare feet of asbestos 10 Days $600 $50
6. ❑ Emergency Asbestos Project or Emergency Demolition Project Prior Notice $50 Emergency Fee
(Single-Family Residences aze exem t from emer enc fee;however, ro owners must rovide a �tten emergency request)
I. I certify that the information contained in this notification & supplemental data is, to the best of my knowledge "�'�i�' � �
a cu te 8 complet `�`'`s��''���.����� ' -
i ,.��, ;,.�4
� '�r �F ��� �z -� ' -
�� �_:
ignature Re resentin ,' y
Date ;� � �,. +�
66-160 Notice of Inte v.2/7/07 RDH 1 of 2
. ���:�:v
. �S ILKI„8�E
'rEsriauG �. raes
Chemical Testing and Consu!ting - lndoor Air Quality Investigations.
Kasey Conners March 5, 2007
2648 S Star Lake Rd
Federal Way, WA 98003
RESULTS OF TESTING FOR ASBESTOS IN BU�LDING MATERIALS
On February 28th, I sampled building materials in the your mobile home, and tested for
the presence of asbestos containing materials (ACM, asbestos over 1%), because you
were planning to demolish. None of the materials were ACM.
The materials sampled by AHERA survey procedures were analyzed by Polarized Light
Microscopy (PLM).
For details about sampling and limitations, see the attached DETAILS ABOUT SURVEY � S
FOR ASBESTOS. °
A� ,
The results of testing 9 samples are listed in the accompanying TABLE OF RESULTS.
No areas were found to be ACM.
MATERIALS NOT INCLUDED:
• The heating furnace and appliances were not dismantled.
. � .
Dr. Richard L. Knights, Ph.D., Analytical Chemistry, President 206-721-2583
Blue Sky Testing Labs, 8655 - 39th Ave. S., Seattle, WA 98118-4517
blueskylab@pobox.com www.inyourair.com fax: 206-721-091�
� March 5, 2007
TO: Kasey Conners, 2648 S Star Lake Rd, Federal Way, WA 98003
FROM: Richard Knights, Blue Sky Testing Labs, Seattle, 206-721-2583
DETAILS ABOUT SUF�VEY FOR ASBESTOS IN BUILDING MATERIALS
TESTED AT:
Purpose of Survey:
To find any asbestos containing materials (ACM), to comply with regulations required by
the Washington State Dept of Labor & Industries and the Puget Sound Clean Air Agency
(PSCAA) prior to any destructive work.
Background Information and Scope of Work:
OWNER: Kasey Conners
DATE INSPECTED & SAMPLED: February 28th, 2007.
AREAS SURVEYED: entire house, except for:
AREAS EXCLUDED: garage
AFTER SURVEY: planned total demolition
Building Description:
BUILDING TYPE: single-family mobile home residence
CONSTRUCTION DATE: built about 1976
STRUCTURAL SYSTEM: wood framing, metal exterior � ,
ROOFING SYSTEM: asphalt shingles, over tarpaper A�"�' �
HEATING SYSTEM: forced-air heating system ducts
Building Inspector and Laboratory:
INSPECTOR: Richard Knights, AHERA Asbestos Building Inspector certification
#1025075 expiring 1/19/2008
LABORATORY: Richard Knights, Blue Sky Testing Labs
Survey Methodology:
PROCEDURE: AHERA sampling protocol in 40 CFR 763.86
LOCATIONS: group into homogeneous areas of suspect ACM to sample
CATEGORtZE: surfacing, thermal system insulation (TSI), or miscellaneous materials
SAMPLING METHODS: teaspoon size, to substrate, into labeled 2x2" plastic bags
RECORDS: list of material types, descriptions, layers, sample locations
Asbestos Identification Process:
ACM LOCATIONS AND RESULTS: all samples listed in the accompanying TABLE OF
RESULTS; no ACM found
Limits of Survey
Asbestos surveys are non-comprehensive by nature and subject to many limitations
including materials that are hidden, patched, non-uniform, or cannot be found with
reasonable ditigence. Reports are not construction specifications. Areas are
approximate. The heating furnace was not dismantled.
. March 5, 20Q7
TO: Kasey Conners, 2648 S Star Lake Rd, Federal Way, WA 98003
FROM: Richard Knights, Blue Sky Testing Labs, Seattie, 206-721-2583
TABLE OF RESULTS OF TESTING FOR ASBESTOS CONTAlNIN6 MATERIALS (ACM) IN BUILDING
TESTED AT: residence, 2648 S Star Lake Rd, Federal Way, INA OWNER: Kasey Conners
SAMPLED: February 28, 2007 REPORT: March 5, 2007 PAGE: 1 of 1
Samples collected from an AHERA survey of possible suspect ACM [40 CFR Part 763.85-86]
Sampled and analyzed by Richard Knights, Blue Sky Testing Labs, Seattle, 206-721-2583
AREA= homogeneous sampling area (HSA) of ACM found.
(no = not found, so less than 1% asbestos fibers; chry =chrysotile type asbestos)
Jdjn.g MATERIAL DESCRIPTION LOCATION l#) Asbestos?
1 _�_,_ SURFACING MATERIALS:
2 No surfacing materials were found (no accoustical, decorative, or fireproofing).
3 �M._ THERMAL SYSTEM INSULATION (TSI) MATERIALS:
4 No TSI was found (no insulation or tape on heating system).
5 _ __ MISCELLANEOUS MATERIALS:
6 � FLOOR COVERING
7 �loor sheet, mosaic, yellow+br�� all rooms no
8 /Floor sheet backing, dark gray, under above all rooms no � S
9 /Adhesive, thin, under above ail rooms no "`
10 Floor sheet, tan + cream straight lines bathroom no
11 /Floor sheet ba�cking, white, under above bathroom no
12 /Adhesive, thin, clear, under above bathroom no
13 _�. WALLS & CEILINGS
14 Wall around bathtub, white+gold bathroom no
15 /Fiberboard backing, dark brown, under above bathroom no
16 Ceiling tiles, brown + white paint bathrpom rb
17 __ MASONRY
18 Mortar, on bricks fireplace, living no
19 � BUILDING INSULATION:
20 Insulation, fibrous, pink walls & ceiling no
21 __ ELECTRICAL INSULATION
22 Wire insulation, plastic, white & black a I I no
23 - - -- - - -- - - - - -- - - - - - - - � - -- - - -
24 __ EXTERIOR SIDING
25 Foam, white, paper faced, under siding N end no
26 __ EXTERIOR WINDOWS
27 No caulking on aluminum windows no
28 � EXTERIOR ROOFING
29 Asphalt shingles, brown W center no
30 /Tarpaper, under above W center no �
31 TOTAL SAMPLES REQUIRED = 9
. � March 5, 20Q�
TO: Kasey Conners, 2648 S Star Lake Rd, Federal Way, WA 98003
FROM: Richard Knights, Bfue Sky Testing Labs, Seattle, 206-721-2583
TABLE OF RESULTS OF TESTING FOR ASBESTOS CONTAtNING MATERIALS (ACM) IN BUILDING
TESTED AT: residence, 2648 S Star Lake Rd, Federal Way, WA OWNER. Kasey Conners
SAMPLED: February 28, 2007 REPORT: March 5, 2007 PAGE: 1 of 1
Samples collected from an AHERA survey of possible suspect ACM [40 CFR Part ?'63.85-86]
Sampled and analyzed by Richard Knights, Blue Sky Testing Labs, Seattle, 206-721-2583
AREA = homogeneous sampling area (HSA) of ACM found.
(no = not found, so fess than 1�/o asbestos fibers; chry = chrysotile type asbestos)
i� MATERIAL DESCRIPTION LOCATION f#) Asbesto,s?
1 _ .� SURFACING MATERIALS:
2 No surfacing materials were found (no accoustical, decorative, or fireproofing).
3 ______ THERMAL SYSTEM INSULATION (TSI) MATERIALS:
4 No TSI was found (no insulation or tape on heating system).
5 _�___ MISCELLANEOUS MATERIALS:
6 _.. FLOOR COVERING
7 Floor sheet, mosaic, yellow+brown all rooms no
8 IFloor sheet backing, dark gray, under above all roams no
9 /Adhesive, thin, under above ail rooms rb
10 Floor sheet, tan + cream straight lines bathroom no
11 /Floor sheet ba�cking, white, under above bathroom no
12 /Adhesive, thin, clear, under above bathroom no
13 __ WALLS & CEttINGS
14 Wall around bathtub, white+gold bathroom no
15 /Fiberboard backing, dark brown, under above bathroom no
16 Ceiling tiles, brown + white paint bathrpom no
17 __ MASONRY
18 Mortar, on bricks fireplace, living no
19 _ BUILDING INSULATIQN:
20 tnsulation, fibrous, pink walls & ceiling no
21 __ ELECTRICAL INSULATION
22 Wire insulativn, plastic, white & black a I I no
23 - - - - - - - - - - - - - - - - - - - - - - - - - - - -
24 __ EXTERIOR SIDING
25 Foam, white, paper faced, under siding N end no
26 __ EXTERIOR WINDOWS
27 No caulking on aluminum windows no
28 __ EXTERIOR ROOFING
29 Asphalt shingles, brown W center no
30 /Tarpaper, under above W center np
31 TOTAL SAMPLES REQUIRED = 9
�HK-15-CU,UI 1hU IC�Uy rc1 Cast�ate runtic nea�cn � rnn ir�. �cuucou���o � . �.�
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HEALTNY�TeOPLE. HEALTNY C0IAMUNI'f'IE9. • '
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� Confidential Health informatian May Be Enclosed .
. Health care rformation is persona! and sensitive informstion related to a person's health care. It is '
bei�g faxed to you after appropriate authorizstbn from the dient o� under circumstances that don't �
requlr� cli�ntl auNwriz�tlon. As the��ecipie�t, you are vbligated �to maintain it in a safe, secure and
cdnfldential manne�.Re-disciosur�withou/additional cHent conserit or as perrnitted hy law is prohiblted. .
Unauthoiized re-disclosure o��a�u�e to maintain cvnfidentlatity cbuld subject you to penalties desarbed
in feder�l ari state law.
IF YOU R�CENE THIS FAX IN ERF70R� PLEASE CONTACT THE SENDER AND .
SHRED THIS �AX AND ALL ACCOMPANY.ING DOCIJMENTS �
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� � Date Pa es includin this a e
To ' Fro�
Phone� �I Phone �
Fax � Fax
RE: I Email ' f�metrokc.gov
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� ❑ URGEN l Plsase process the attached order a��'�
� For your information . [�] Please sign the attached and return
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Instructions for complering form: This form is w be completed by any persons permanently rcmoving a
septic taTilc, seepage pit, cesspool, or.other on-site sewage system wastewater tanks from service.
Coniplete and submit this report to the health officer within thirty (30) days of the abandonroent.
Authori : Cha tcr 13.04.054,the Code of Kin County Board of Health,Title 13.
Return Compt�ted Form to the Following address: Date Receivcd:
Eastg�te Public Health Center
14354 S�Eastgate Way
Bellevue,WA 98007 Phone(20�296-4932
General Yn[ormatiou(Please print):
Name of Owner/Occupaat of op�iy:
Addnss: to
Tctephon�: �
Date of Report: �/�/ � .
Wnstewater Tsnk Data:
Type of Sewagc Tank:LC Sepric Tank _Pu�np Tank ��Tolding Tank _Other: ••� �'
Number of Compartments Pumped: _ _/ "°
Number of Gallons Pumped: 75-� �
Checktist Ttem Yes No Not Applicabte Comments
S ta e removed b an a mved um er?*
Tazilc lid rEmovcd or destro ed? x
Tank void filled vc�ith com cted soil? X
*OSS Pumper Na�me: (.����� 7—S�c��j
King County Certification Number: ,y-//8 �
Reason tor w�stewater taok abundonment:
�C�,Property beins scrved by public sewers ,,,Property being served by replacement tank
Comments: � ' •
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Sieaature. � Date:�,�,/,�/C��-
Report of WAetewater 7ank Abundonment: Pdnt Datc 5/12/99 Forms/sewaedfarm.96
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March 16, 2007
���"�� Serving the Southwest Metropolitan Area since 1946
To Whom It May Concern:
The water service at 2648 S Star Lake Rd has been turned off for construction purposes.
Greg L. Wilson
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Customer ervice Supervisor
Highline Water District
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23828 - 30th Ave. S. • P.O. Box 3867 • Kent, WA 98032 • (206) 824-0375 / FAX: (206) 824-0806