HomeMy WebLinkAboutSEP2012-00051 Jefferson County Department of Community Development
621 Sheridan St., Port Townsend WA 98368, (360)379-4450
SEPTIC PERMIT APPLICATION
PROPERTY OWNER /Oc7,'7/C/ /74 5'eif
MAILING ADDRESS .1°0 z'®X S75—
Ch 4 . 11 WA' 9'33i3
PHONE ( 360 ) 73Z 7e)/
SYSTEM DESIGNER ri',D Designer Phone# 3(® 673"9"c
0
LEGAL DESCRIPTION: Section IS Township Z9/1"/ Range / PARCEL# 90 if— /-.:5- v
Subdivision Name Division Block Lot(s)
Site address/Directions to site /2 q/ k/e57 V4,//e,y /a
SOURCE OF S1 AGE/USE TYPE p, WORK WATER SO CE
Residential CO-- New F Tank/s only Private
Residential Al U Modification Public
Commercial Expansion
Community Upgrade
Repair SITE SIZE Si Z.0 97857
SYSTEM TYPE Partial Repair-(tank) (drainfield) Previous Evaluation r Am,Conventional Designate Reserve Area Yes#
Alternative Redesign No 40
SYSTEM DETAILS
Number of Gallons/day 6 Soil type 3 (attach soil eval.) Application Rate °`811
` gal.lsq.ft./day
d/
Drainfield Length ? 5`0 ft. Trench Width 3 ft. Trench/Bed Depth 3 6` in.
Septic Tank size /1-50 gal. Pump C amber size /I, gal.
TYPE of system C---/f C®rvt,
By signing the application form, the applicant/owner attests that the information provided herein is true and correct to the best of
their knowledge. Any material falsehood or any omission of a material fact made by the applicant/owner with respect to this
application packet may result in this permit being null and void. I further agree to save, indemnify and hold harmless Jefferson
County against all liabilities,judgments, court costs, reasonable attorney's fees and expenses which may in any way accrue against
Jefferson County as a result of or in consequence of the granting of this permit.
I further agree to provide access and right of entry to Jefferson County and its employees, representatives or agents for the sole
purpose of application review and any required later inspections. Staff's access and right of entry will be assumed unless the
applicant informs the County in writing at the time of the application that he or she requires prior notice. Inspections shall occur
during regular business hours. Initial here if you require notification before entry
Appeal—A person aggrieved of a decision of the Health Officer may appeal. Appeals shall be submitted to the Health Division in
writing within fifteen days after receiving written notice of the decision.
DISCLAIMER-This application is for an on-site sewage system that meets the state and county
standards in effect on the date of application. This application for an onsite sewage system DOES
NOT assure you of any other County approvals. For example, it DOES NOT GUARANTEE that
you will later obtain permission to build a permanent residence or other structure on this parcel. Any
future ap lication will be separately judged by the rules and laws in effect at that time.
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i ` 072-0/ Z.
Property Owner Signature /
FOR OFFICE USE ONLY
C asl /PARTIAL ASBUILT /. , FINA 17
40b/
OVED �� ), 1 6
INSP/PUMP TEST ` ,
ALL HOLD REQ. MET
Dated y 2`l Z Fee —�(� � Rec# Check# /� 7 Case#SE /02- C (
H:\wEti\pDFs\septic\septic_permitapp_2008.Doc
JEFFERSON COUNTY PUBLIC HEALTH
615 Sheridan Street •Port Townsend•Washington •98368
www.jefferson countyp ub lichealth.o rg
Phone 3tiU-373b-9444 ha.x -
ON-SITE SEWAGE DISPOSAL PERMIT
PERMIT #: SEP12-00051 Date Received: 05/07/12
Date Issued: 08/16/12
SITE ADDRESS: 1291 WEST VALLEY RD
CHIMACUM, WA 98325 Date Expires: 08/16/15
APPLICANT: DAN SHAW PHONE:
PO BOX 515
CHIMACUM WA 983250515
LEGAL DESCRIPTION: S15 T29 R1W TAX 36 PRCL D V30/P185 BND TGTH THRU BLA#107272
PARCEL#: 901154001 Section: 15 Township: 29N Range: 01 W
DESIGNER: ERIC HIBBARD PHONE: 360-683-6300
SOILS APPLICATION INC.
P.O. BOX 1120
CARLSBORG WA 98324
SYSTEM DESCRIPTION: CONVENTIONAL TRENCH
No. of Gallons per Day: 600 Type of work: NEW
Drainfield Trench Septic Tank
Length: 250 feet Width: 3 feet Depth: 36 inches Size: 1,250 gallons
DISCLAIMER-This approval is for an on-site sewage system that meets the state and county standards in effect on the
date of application. This approval for an on-site sewage system DOES NOT assure you of any other County approvals. For
example, it DOES NOT GUARANTEE that you will later obtain permission to build a permanent residence or other structure
on this parcel. Any future application will be separately judged by the rules and laws in effect at that time. All construction
and development activities must comply with all permit conditions, state and local codes, and Recommended Standards and
Guidance documents in effect when the permit is issued.
The property owner is responsible for the accurate location of all property lines.Any removal of or major disturbance of soil in the
primary or reserve drainfield area may create site conditions that are unacceptable for the installation of a sewage disposal system.
Any change in drainfield or tank location may invalidate this permit unless prior approval is obtained from the Jefferson County
Environmental Health Division. If during excavation or development of the site an area of potential archeological significance is
uncovered, all activity in the immediate area shall be halted, and the UDC Administrator shall be notified at once.
Permit issued to CONSTRUCT, ALTER, REPAIR OR MODIFY AN INDIVIDUAL SEWAGE DISPOSAL
SYSTEM IN JEFFERSON COUNTY, WASHINGTON
This permit is issued for a period of three years (unless otherwise stated above) in accordance with
Jefferson County Rules and Regulations for On-Site Sewage Systems, codified in JCC 8.15 as amended.
This permit may not be renewed.
/7//7/
Jefferson County Envir nmental Health Specialist
This permit with conditions must be onsite during II phases of construction
HEALTH DEPARTMENT MUST BE CONTACTED FOR FINAL INSPECTION.
SPECIAL CONDITIONS APPLY SEE ADDITIONAL PAGES
CONDITIONS OF APPROVAL - PERMIT NO.: SEP12-00051
1.) Distribution boxes shall be fitted with a riser to grade, constructed of durable materials and a
secured lid, adequately sized to allow visible inspection of the liquid level in the box.
2.) Divert all sources of drainage, including roof drains away from septic tank and drainfield area.
3.) Any clean outs installed to grade in the transport line MUST be in a riser that is semi traffic rated for
farm machinery, etc. Recommend installing well below grade and mark with a steel post.
4.) H -An asbuilt drawing and certification of completion by the Designer is required prior to final
approval.
5.) H - AS PER WAC 246-272A AND JEFFERSON COUNTY CODE 8.15 ALL ONSITE SEWAGE
SYSTEMS REQUIRE THAT A RESTRICTIVE COVENANT REGARDING THE MONITORING OF
THE ONSITE SEPTIC SYSTEM BE RECORDED TO THE PROPERTY TITLE. THE PROPERTY
OWNER SHALL ASSURE THAT MONITORING IS PROVIDED BY AN APPROVED ENTITY AT
THE FREQUENCY DEFINED PER STATE WAC 246-272A AND JEFFERSON COUNTY CODE
8.15 AS ADOPTED OR AMENDED.
A COPY OF THE RECORDED OPERATIONS AND MONITORING AGREEMENT IS REQUIRED
PRIOR TO FINAL APPROVAL OF THE SEWAGE DISPOSAL PERMIT
6.) Designer must be contacted prior to start of construction and for inspections during installation.
DESIGNER IS REQUIRED TO DO A PRECOVER INSPECTION ON ALL TYPES OF SYSTEMS.
7.) Notification of the start of construction shall be faxed or emailed to Jefferson County Public Health
ONE WORKING DAY prior to start.
8.) Before final approval is given, the designer shall provide an operations and maintenance manual to
the property owner and the Health Department. The manual must instruct the owner of the on site
sewage system on the ways to properly operate and maintain all components of the system.
9.) Approval of this sewage disposal permit does not preclude the permit holder from complying with
the Unified Development Code for other/future development on the site.
10.) The project shall adhere to the Best Management Practices (BMPs) to control stormwater, erosion
and sediment during construction. BMPs shall address permanent measures to stabilize soil
exposed during construction, and in the design and operation of stormwater and drainage control
systems.
11.) All construction and development activities must comply with all permit conditions, Washington
State and Jefferson County Codes and Recommended Standards and Guidance documents in
effect when the permit is issued.
12.) Approval/issuance of a sewage disposal permit does not guarantee the approval of other
development or a building permit on this site. Compliance with other Jefferson County and
Washington State Codes is required.
13.) Jefferson County has determined that the use of real property for agriculture and forestry
operations is a high priority and favored use in the county. The county will not consider to be a
nuisance those inconveniences or discomforts arising from such operations, if such operations are
consistent with commonly accepted best management practices in compliance with local, state, and
federal laws. If your real property includes or is within five hundred (500) feet of real property
designated as Rural Residential 1:10 or 1:20, Rural Industrial, Rural Commercial, Agriculture, or
Forestry, you may be subject to inconveniences or discomforts arising from such farming and
forestry operations, including but not limited to noise, tree removal, odors, flies, fumes, dust,
smoke, the operation of farm and forestry machinery during any 24-hour period, the storage and
disposal or manure, and the application of permitted fertilizers and permitted pesticides. One or
more of these inconveniences may occur as a result of agricultural and forestry operations which
are in conformance with existing laws and regulations.
SEP12-00051 Page 2 of 2
\\tidemark\data\forms\F SEP_Permitmod.rpt 8/16/2012
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CONVENTIONAL SYSTEM ASBUILT INSPECTION REPORT
INSTALLER p i,I/v �}�/� PARCEL# 9 /
Permit Owner ivi '�F' A Permit # I -a— or),57
ABSORPTION AREA: •
DRAINFIELD TRENCH TRENCH —z), TANK `' #OF #GAL/
LENGTH 2-.5V WIDTH DEPTH 56 T SIZE / BEDRMS DAY g7-65-4vc 4/4/ -
Tank Shroud/ --
r
IF PUMP AND PUMP CHAMBER REQUIRED: Size Screen C-077c;71"/ T
Float Arrangement
Highmater_float—distance to top of tank/emergency storage
Dose drawdown (#of inches) #Gallons/Dose
Timer/Dose Counter info Pump Size/Manufacturer
I CERTIFY TH •NSITE SEWAGE SYSTEM WAS INSTALLED AS DSIGNED, PER PLAN APPROVED
r-/9-41 f)ATF
INSTALLER SIGNATURE DATE INSTALLED
l • e`
+••Ir/
f� R ;
�►4f Alamo •'
ERIC IwBBARD
A/ UtNSED DESIGNER :I,
EXPIRES 11-18-20
ASBUILT CONVENTIONAL I-RM_05-10-04.pdf
2291 WEST VALLEY RD
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Jefferson County Environmental Health Dept.
615 Sheridan St., Port Townsend, WA 98368
SOIL LOG #5-8 WILL NO BE USED FOR DESIGN OF SEPTIC OR RESEVE AREA
BECAUSE OF PROXIMITY TO SUPPOSED WETLAND.
SOIL LOG #9 f31, ,T.4 Health Dept. Comments:
0" to 12": DARK BROWN LOAMY FINE SAND
12" to 24": RED BROWN LOAMY FINE SAND
24" to 72": TAN GRAVELLY MEDIUM SAND
Observed water table @ n/a ma,v,1. ��+I
Roots to 60" �� d �
SOIL LOG #10 "..1.- ',/9"11," Health Dept. Comments:
0" to 9": DARK BROWN LOAMY FINE SAND
9" to 22": RED BROWN LOAMY FINE SAND
22" to 70": TAN GRAVELLY MEDIUM SAND
Observed water table @ n/a
Roots to 50"
SOIL LOG #11 4(0 ct Health Dept. Comments:
0" to 10": DARK BROWN LOAMY FINE SAND
10" to 38": RED BROWN LOAMY FINE SAND
38" to 72": TAN GRAVELLY MEDIUM SAND
Observed water table @ n/a f / 4
Roots to 60"
SOIL LOG #12 46.1g i t/ Health Dept. Comments:
0" to 8": DARK BROWN LOAMY FINE SAND
8" to 23": RED BROWN LOAMY FINE SAND
23" to 72": TAN GRAVELLY MEDIUM SAND
Observed water table @ n/a 64
Roots to 60"
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Jefferson County Environmental Health Dept.
615 Sheridan St., Port Townsend, WA 98368
SOIL EVALUATION
Property Owner-DAN SHAW
System Designer- Soils Applications LLC. ERIC HIBBARD
LEGAL DESCRIPTION: Section-15 Township- 29N Range- 1W Parcel# 901-154-001
Subdivision TAX#36 PARCEL D V30 P185 Lot(s)-
Date Logged: 3-10-2012 & 4-17-2012 Logged by: Eric Hibbard
Include soil textural characteristics and depths at which significant changes occur. Be sure to
include depth where mottling or impermeable layers occur.
SOIL LOG #1 Health Dept. Comments:
0" to 9": DARK BROWN LOAMY FINE SAND
9" to 16": RED BROWN GRAVELLY MEDIUM SAND
16" to 70": TAN GRAVELLY MEDIUM SAND
Observed water table @ n/a 1
Roots to 60" �,/
SOIL LOG #2 Health Dept. Comments:
0" to 11": DARK BROWN LOAMY FINE SAND
11" to 44": RED BROWN GRAVELLY MEDIUM SAND
44" to 70": TAN GRAVELLY MEDIUM SAND
Observed water table @ n/ar r
Roots to 52" M ��
SOIL LOG #3 Health Dept. Comments:
0" to 11": DARK BROWN LOAMY FINE SAND
11" to 30": RED BROWN GRAVELLY MEDIUM SAND
30" to 74": TAN GRAVELLY MEDIUM SAND
Observed water table @ n/a
Roots to 60"
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SOIL LOG #4 Health Dept. Comments:
0" to 9": DARK BROWN LOAMY FINE SAND
9" to 24": RED BROWN GRAVELLY MEDIUM SAND
24" to 72": TAN GRAVELLY MEDIUM SAND 9ej
4 AA
L
Roots to 52" tai/'
Fir'
t� 5;OOa
MEWED DESIGhk-