HomeMy WebLinkAboutSEP2014-00155 JEFFERSON COUNTY PUBLC.- CT\ St?IC HEALTH
S• C�UN U
�f � = 615 Sheridan Street • Port Townsend •Washington •98368
www.jeffersoncountypu blichealth.org
CERTIFICATION OF TANK ABANDONMENT
v 204
Parcel number q`1 ` 2Ot jD2. *( 3
Address 331 L1 INVJ'i tit Nue- flee ti►A2-
Property Owner Name ,5t C A r- :-t S � 1111 ,ncaw
Septic Permit# (if applicable)
Individual/Company Certifying Abandonment
s ( Pi,r-\ Ciaa.rels
Phone Number
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 Date
Print Name (5,...v.;
Pump receipt attached
COMMUNITY HEALTH PUBLIC HEALTH ENVIRONMENTAL HEALTH
DEVELOPMENTAL DISABILITIES WATER QUALITY
MAIN: 360-385-9400 ALWAYS WORKING FORA SAFER AND MAIN: 360385-9444
FAX: 360-385-9401 HEALTHIER COMMUNITY FAX: 36(385-9401
•
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Arness Septic Pumping
22777 Indianola Rd NE
Poulsbo, WA 98370
Customer's
Order No. D� Iir
FName 2 /� __-
Address
SOLD C.Q.D. CHARGE ON ACCT. MDSE.RETD. PAID OUT
QUAN. DESCRIPTION PRICE AMOUNT
W dhAef Arrive _
Depart
, - ---&-Q (OLAAP;')2
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/et k
57U .. ci„, t/(-74- __,
All claims and ietUmedgabds musrbe accompaned by tilts bit. TAX
97461 Received by TOTAL,./7
m BUSINESS FORM 55-5813T MADE IN .S - n
�� I ICI'..\�.I• •�� I I I�N M ��� ���.�IM �I ■••I •ID 'AI,
' .- SEPTIC TAW PUIIIPING t INSPECTION REPORT FORM
Cie!I Center—615 Wit, Port Townsend,WA
•
/-1 r ! _.../ '- Jul # # / _ . /mod 0 / •_
Nun*of• - or Contact Person Site Address City - .•Zip Code
Date of inspection -• Assessors account# 9q/ -O l 3
• •
• SEPTIC TANK - •
Esumated Tank size.5llgal 0 METAL CONCRETE ❑ POLYETHYLENE •
•�'lE ❑07HR s:rttm�torn.•
E::dcnce of ground water intrusion? ❑ YES ❑ NO .
tank grater than 12"below grade? . YES* ❑
. •NO *If"YES",how dap(inches)?
:s:nser installed? ❑ YES ❑ NO
•
i:fiuent from drainfield backing into tank? ❑ YE! ❑ NO
snuuon of baffles. ❑ GOOD 0 NONE 0 NEED REPAIR or as
•
snort acowman
ff.eat screen, cleaned? ❑ YES 0 NO ❑ NONE 0 NEED REPAIR wuuo
:*33 the Septic Tank pumped? ` YES ❑ NO
::ere both compartments pumped? ❑ YES ❑ NO ' /SINGLE COMPARTMENT
PUMP TANK .. •. •
(check lrapplicabl•) . .
•
!s there a pump tank? ❑ YES 0 NO
.s 3 nser installed? ❑ YES ❑ NO
ti tank greater then 12"blow grade? ❑ YES• ❑ NO *if"YES",bow deep(inches)?
Estimated PutnpTank size gal. ❑ 'METAL • ❑ CONCRETE ❑ POLYETHYLENE 0 OTHER:roan tx cmeas..s
Was the Pump Tank pumped? ❑ YES ❑ NO* •If"NO",explain in comments.
-_:rp Tank screen cleaned(if present)? ❑ YES 0 NO• . •1f"NO",explain in comments. •
iF MEASUREMENTS WERE TA KEN Or SCUM AND SLL'DCE LAYERS,PLEASE RECORD SELOW:
. 1ST COMPARTMENT 2ND COMPARTMENT •
::ram of floating mat in let compartment inches Depth of floating mat 2nd compartment meta:
Depth of sludge in 1st inches Depth of sludge in 2nd compartment , • inches-
Total depth including mat.sludge and clear zone inches Total depth ittalndi -
/n -- j� n���udg�and cfeat•.r .macs •
COMMENTS, / -�� � .
3C- .
fitti.)
ATURE F I ii "
O PUMPER A / S PUMPING COMPANY_ ��7�7 . 12>�1 >
ress report indicates the cotididort of the above septic tank(s),aadlcr pump tank(s),at the time of inspe doa and pumping. In no way �lti guarantee try
:t•c ey%ill continue to fttaodon sods drily.
•WAC 146.272•15SO! The OSS owner shall employ an approved pamper to remove the septagc from the tank when the solids and the scttsa•intdcat: -
foot removal is necesservt 4 septic tank should be lnt;pettied every three yrars and pumped only when needed If the combined sludge artd solOs ezued.l;l'
:he:owl mime of the first compartment and/or 1/3((the total volume of a single compartment 1a4 fr U. sledge**pia its thmri 12 i des from me
s,uorn of the outlet tee and/helloed":mat is less than'.i inches from,*bottom of the owlet tee or/inch from the top of the otde tee.then die'tonZ shone- .
oe pumped. If the rank is pumped too often however,the proper separation and biological moment occurring n the tank can be Innr %
og• g' paired.tartan.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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