HomeMy WebLinkAboutSEP2014-00154 c.. alt-N ce\arNe- ,
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' JEFFERSON COUNTY PUBLIC HEALTH
4 *Vtl:,1 615 Sheridan Street • Port Townsend •Washington •98368
'14'111 O'C't8
www.jeffersoncountypublichealth.org
8
CERTIFICATION OF TANK ABANDONMENT
Parcel number 9q11-0 I 'TO <51-
Address LI NI tite
Property Owner Name CCiict•AL. '1146,V6e-tt,N AtNle-Qz boa* Cs-Yzme
Septic Permit# (if applicable)
Individual/Company Certifying Abandonment
4111 ( C
Phone Numbeb
I certify that the septic tank and/or pump chamber on the above referenced site
has been abandoned to Washington State and Jefferson County Public Health
Requirements.
Signature DatecQ—4
Print Narnte (._.
Pump receipt attached
COMMUNITY HEALTH PUBLIC HEALTH ENVIRONMENTAL HEALTH
DEVELOPMENTAL DISABILITIES ,., QUALITY
MAIN: 360385-9400 ALWA WORKING FOR A SAFER AND MAIN: 360385-9444
FAX 364385-9401 HEALTHIER COMMUNITY FAX: 360385-9401
. 0
•
y •
Arness Septic Pumping
22777 Indianola Rd NE
Poulsbo, WA 98370
Customer's
Order No. Date r)71L-5/1/4/
Name 24.'a 1 r --.54`
Address c , e t L. ( ci— 2
p / o_ii/z_v____,
SOLD B CASH C.O.D. CHARGE ON ACCT. MDSE.RETD. PAID OUT
QUAN. DESCRIPTION PRICE AMOUNT
A T
Arrive
Depart
rec
A5.--z?-se) 5 ct, c, /-10Y1Ar-k/Lactf
_____ :6_z__t_,_ /4/,&,,,,,ri,etty
All claims and returned goods MUST be accompanied by this bill. TAX
97460
Received by T AL
REDIFCIRM. BUSINESS FORM 55 58B MADE IN U.S.A. <///7W -
WWI a a awvtst 110sws11 a s a aar•sa.,a a i W i:vatiar%.e111 vra Iiiir wursower TANK PUMPING 8x INSPECTION REPORT FORM
. - ' Cie HI Center—815 Sheridan, Port To msend,WA 98368
•. t
_.',/...../e-, ,..f 1(3 /27/1//e.1_0_, .,i..A0--- 6.../dzie___ 9e. . 97.42
tirrnc of 0 e •r Contact Person Site Address City / .•Zi Code
Date of inspection r / Assessors account)? q 4 6 / 7D 4,-g"------ .
•
SEPTIC TANK . .
•
Esum3tcd Tank size, •• •
❑ METAL . CONCRETE ❑ POLYETHYLENE : 'L�•0T1iER art»,m�r.:
E:edence aground water intrusion? 0 YES /0 NO
fZI
:3 tank greater than 12"below grade? 0 YES' ❑ -NO *If"YES",how deep(inches)?
:s:::set installed? ❑ YES ❑ NO
Effluent(torn drainfield backing in o tank? ❑ Y ❑ NO
•
Csr..,ttwn of tames. ❑ GOOD 0 NONE (] NEED REP AIR or iumauia.sneer aearutxnl
•if fiunt screen. cleaned? ❑ YES ❑ NO ❑
,�°` ❑ NONE NEED REPAIR of rtwwem.srtx:s►•h sc�:rr,:•
:ass the Septic Tank pumped? .ia YES ❑ NO
::ate boot compartments plumped? /I/ YES ❑ NO ' Q SINGLE COMPARTMENT
PUMP •TANK • •
(check If appneable) .. .
!s there a pump tank? ❑ YES ❑ NO .
.3 3 nset installed? ❑ YES ❑ NO
u tank greater than 12"below grade? ❑ YES* ❑ NO •If"YES",bow deep(inches)?
Estimated PumpTank size gal. ❑ 'METAL . ❑ CONCRETE ❑ POLYETHYLENE ❑ OTHER warm co :s
Vas the Pump Tank pumped? 0 YES ❑ NO• •1f440",explain in coma.
e.:rp Tank screen cleaned(if present)? ❑ YES 0 NO' . 'If•"Nt&explain in comments. •
•
IE MEASUREMENTS WERE TAKEN Oa SCUM AND SLUDGE WIER3.PLEASE RECORD BELOW: '
1ST COMPARTMENT 2ND COMPARTMENT
Dt.put of floating mat in 1st compartment inches Depth of floating mat 2nd compartment • :noes
Depth of sludge in 1st comparuneea inches Depth ofsludge in 2nd compartment , • irwha•
Yowl depth including mat,sludge sod dear zone •
inches .• .... •
Ttusl drlptb' runt,sludge and ofar:�oae imdrs .
COMMENTS, Cgvis a4.64 f't-•_,Y-iti_ 7
7-
. . .
'Pa- .
. • / . .
_1 . .tTURE OF PUMP / /1i •LIMPING COMPAAlY SS S • '�_a J -
�pon indicates the candidat of the .• septic tank(s),and/cr pump tanks) at the time of and In doer~
This r r � pumping. way tt gw�t
::•trcy will continue to tondos*: . .
•%VAC 246.272.15501 The OSS owner shall employ an approved pumper to remove the septage from the tank when the solids and dpi sew iadicaR -
mat removal is neeessarv;,i Mk should be Itttpeead every three years and pumped only when needed If the combined sludge ant:Olds s peed.1;9
:he:Drat volume of the first compartment and/or 1/3 of the totel eo ume of a single comportment tangy gr Vibe sludge layeris leas than 12 iages(roar cure .
..horn of the outlet tee and*floating mat is less than 3 itches fr+or*the bottom of the outlet tee or 1 Inch from the top of the cider tee.then Ai tcnt sitouia• . .
oc pumped. If the tank is pumped too often howrvter the proper separation and biological treatment occurring in the tank can be Impaired leading to possible -
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FOR INFORMATIONAL PURPOSES ONLY-
Jefferson County does not attest to the accuracy of the data contained herein and makes no warranty with respect
to its correctness or validity. Data contained in this map is limited by the method and accuracy of its collection.
Tue Dec 24 08:53:37 2013
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