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JEFFERSON COUNTY PUBLIC HEALTH
615 Sheridan Street • Port Townsend •Washington •98368
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www.jeffersoncountypublichealth.org
CERTIFICATION OF TANK ABANDONMENT
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Parcel number 611 I2,o i SH 0
Address ckm k.. Pi\urvc.;:( Am-t (.... .A.k C.-e t■sk. 33Q1 9C—r Qd)ri c'eco f-ct
Property Owner Name 4,..„o 0;,,..reptt -'to,le""1,1 ei,‘A....4.iv...3- '2wkin
Septic Permit# (if applicable)
Individual/Company Certifying Abandonment
-A, . lb.'" of ■ - Mir_ — _:..—all.I. - ." a ,■•• ii-,..s
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.
7)14.ow""il
Signature 4.---4------Date
Print Narn." 5
Pump receipt attached
COMMUNITY HEALTH ENTAL HEALTH
DEVELOPMENTAL DISABILITIES PUBLIC HEALTH ENVIRONMENTAL QUALITY
MAIN 360-385-9400 ALWAYS WORKING FOR A SAFER AND MAIN:360.385-9444
FAX 360-385-9401 HEALTHIER COMMUNITY FAX: 360385-9401
•
0 ... - -
•
11 tQ 3t $t
Arness Septic Pumping
22777 Indianola Rd NE
Poulsbo, WA 98370
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Customer's '
Order No. Date ,/''' '''. 7 4/
l
/
Name I /.. -.:S
Address -. sC nein flu / '
if0 f E-111,-e.
SOLD BY CASH C.O.D. CHARGE ON ACCT. MDSE.RETD. PAID OUT
QUAN. DESCRIPTION PRICE AMOUNT
Arrive __,____
C)c j\ji.ivt()_cik Depart
A/ ' l:`/ .,nw.,..,.... ....
AID _
. t---
All claims and returned 9004$MU$T be accompanied by this al
TAX
97462 TOTAL
�jyp� � Received by ///J��
'�'".. i4:1's BUSINESS FORM 55-58BT MADE IN U.S.A. `?� /V //,
mi• • a wawa aasy g a la •••-w W a ir ■ s •law/ear aim a a a w a I•11/11144/Y s MP MMM w..• ••■• •
• SEPTIC TANK PUMPING & INSPECTION REPORT FORM
Cie HI Celt-615 Sheridan, Port T send,WA 98368
2 tJ1 rs • C. Mud&gyp 0/) 0.“-i.ae_e_R 0 gg3 76.
Nance of Owner Contact Person Site Address City .•Zip Code
Date of inspection . 31 Assessors account# 9 / 4c---7.6
•
/ • SEPTIC TANK - -
Estimated Tank sixes A 0 METAL • CONCRETE ❑ POLYETHYLENE : '0•071.0mrr ;s: •
E-adence of ground water intrusion? ❑ YES 0 NO
:,,ank greeter than 12"below grade? 0 YES* ❑ O. a
N If"YES".how deep(inches)? ,,,
:s:riser installed? ❑ YES ❑ NO
_ftlnant from dr:infield backing into tank? 0 YES `t NO
�on.rton of baffles.
•
❑ GOOD 0 NONE ❑ NEED REPAIR ur ammo.sfaan•at cowte net
Effluent screen. cleaned? ❑ YES 0 NO 0 NONE •
❑NEED REPAIR OF sw�.srscry:.%souacr:;;:-
:vas the Septic Tank pumped? i YES 0 NO
• :cre both compartments pumped? 0 YES ❑ NO • ASTNOLE COMPARTMENT
PUMP •TANK • •.•• • •
(cheek If applicable) • •
Is there a pump tank? ❑ YES 0 NO
•
.s a nser installed? 0 YES 0 NO
is tank greater than 12"blow grade? ❑ YES* ❑ NO •If»YES»,bow deep(is)?
Estimated PumpTank size .gaL ❑ •METAL • ❑ CONCRETE ❑ POLYETHYLENE O OTHER VIM,„co n
:ties the Pump Tank pumped? 0 YES 0 NO* •u»H0",explain in comments.
e_:.p Tank screen cleaned Or present)? ❑ YES ❑ NO* • •If"NO&'.explain in comments. : •
_if MEASUREMENTS WERE TA KEN Ow SCUM AND SLUDGE LAM:3.PLEASE:RiCORA BELOW:
1ST COMPARTMENT 2ND COMPARTMENT -
eawof floating mat in Is;compartment _ _,,,,_.inches Depth of floating mat 2nd compartment :macs
Depth of sludge in 1st eomparuaau inches Depth of sludge in 2nd compartment inches*
• Total depth including matt.sludge end clanzone inches Total depth including mat,sludge and
cifeafmae .••• : itches• .
COMMENTS, 6Ad / — Ve �� .
TO-- .
•
( TURE OF PUMP iii / 14 PUMPING COMPANY 4$NESS-Ss •Paw p S _
'?•rrs(cpott indicates the coddi • the above septic . ),anther putty tanlc(s),at the tithe orinipet oa and pumping. its no way does u gui
:vtifey v.dl continue to function savorily.
•11'AC 246-272.1 SSOl The OSS owner shell employ an approved pumper to remove the septage from the tank when the solids snd_the scumLS/licatc
Ma[a t removal is tteassarvt d Katie tank should be ilupeeted suety three yew and pumped only when needed If the combined sludge and muds exceed.G 1'
:he:orai volume of the fust compartment and/or 113 of the total vo tune ofa single cosrpartment tank,gr ffthe sludge layerfs/ifs*pi 12 inches jozr me
s.uoas of the outlet tee and*floating mat is lest ihoti3 inches frons the bottom of the outlet tee or l inch front the top of the"let tee.ten thr'.tanf scour•
or pumped "the tank is pumped too often however,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
o 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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12/24/2013
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