HomeMy WebLinkAboutSEP2014-00027 SEP14-00027
NOT VALID
SYSTEM DECOMMISSIONED AS OF 10/1/14
CONNECTED TO CITY OF PORT TOWNSEND
SEWER
JEFFERSON COUNTY PUBLIC HEALTH ii*' M
zat. 615 Sheridan Street • Port Townsend•Washington •98368
www.jeffersoncountypublichealth.org
• CERTIFICATION OF TANK ABANDONMENT
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Parcel number
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Address t CAE C O MVTT L Lk jt \a ,1 n 4
Property Owner Name Ts 4. V14 '
Septic Permit# (if applicable) N
Individual/Company Certifying Abandonment
Mow\1 Z ALL
Phone Number 5-60 — 3E55— L(115
I certify that the septic tank and/or pump chamber on the above referenced site
has been abandoned to Wa i gton State and Jefferson County Public Health
Requirements.
Signature Date `
(29' 1 (
Print Name 10
• Pump receipt attached
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COMMUNITY N S PUBLIC HEALTH ENVIRONMENTAL E HEALTH
QUA TY
MAIN.360385-9400 MAIN: 3603854444
FAX 360-385-940; HEALTHIER COMMUNITY FAX:3603854401
ENiddR (;HECK L.L.C.
1612 Hastings Ave, W, 228347
Port Townsend, WA 98368
Invoice PH 360-379-9400
TO SHIP TO
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ADDRESS ADDRESS
CITY,STATE,ZIP CITY,STATE,ZIP
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ENVIRO CHECK, L.L.C.
1612 Hastings Ave. W
Port Townsend, WA 98368
0 360-379-9400 SEPTIC TANK OPERATIONAL REPORT «C r 1 2014
Company Name 1.. 4. ) t 11/1C r` I / I- Date of Service F, —`r l AIr .
Technicians signature >----.% --, -
Service provided for \r. ;i (.. LAi ''t i
Address i. ° `- ,, , =", 7 1 1...�1 .
a
Phone
Job Address c i ,, F+.-ai.Jl,_
Last Date Pumped . ,%N IA •, r O'' #people in home I #bedrooms ?,u li
SEPTIC TANK
Size of tank \ tt,,- r< Gallons Compartments: Single 4 Double
Material: Concrete ' Polyethylene Metal Other(specify)
Conditions of septic tank: Good Poor
Was ground water observed leaking into tank?Yes No \r
If yes, where was water observed?
Effluent running back into tank from drainfield? Yes No
Riser to grade on inlet Yes No 4 Riser to grade on outlet: Yes No
If no risers, were risers installed? Yes. No
Solids in Tank: 1st compartment Scum (top layer) `; in. sludge(bottom layer) it in.
2nd compartment scum (top layer) in. sludge(bottom layer) in.
BAFFLES
Condition of inlet baffle: Good Needs Repair A. Repaired Material
Condition of center baffle: Good Needs Repair Repaired Material
Condition of outlet baffle: -Good - Needs Repair Repaired Material I '.,�.r
Type of outlet baffle: Unscreened k Screened Filtered Material
Cleaned outlet baffle and/or screen: Yes No
PUMP
Does the system include a pump? Yes No ' If Yes, complete the following
Size of Tank Gallons
Riser to grade: Yes No If no, was riser installed: Yes No
Material: Concrete P F,1A-thyle -" Metal Other(specify)
Was ground water observed I aki k•..tank?Yes No
If yes,where wa w r •; rved?
Depth of accumulated sI win-pump" tank inches
Was the tank pumped? Yes No
Recommended additional information
Condition of Pump: Working Not Working Needs repair
Condition of Alarm: Working Not Working Needs repair
Pump cycle drawdown: Inches Time for pump cycle minutes/sec.
Comments: