HomeMy WebLinkAboutSEP1971-00012 Include the following items on your plot plan:
❑ Property boundaries ❑ Wells APR 2
8?015
❑ Names of adjacent streets ❑ Septic tank
❑ Driveways and parking spaces l Drainfield (enter N/V if unknown)
❑ Surface water(ponds,creeks, etc) ❑ North Arrow
❑ Buildings(residence, sheds, garages, etc)
/aDORESS— mil\ S��SeI �L' c RT• v
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EN VIRWt H C , L.L.C.
NOT TO SCALE 1612 Hastings Ave. W.
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Part Townsend, WA 98368
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Jefferson County Department of Community Development f '� �j
2006 621 Sheridan St.,Port Townsend WA 98368,(360)379-4450 ••- ,,�',W ''4, It
SEPTIC PERMIT APPLICATION %t' le �!`I.
PRO• i `' e I I e.A tLrcQ /h' fiu l' `�` 4 uz�fl ,,II
MAILING ADDRESS 4/1 Sj,U,.i5._4-- "8 1 I. BERNT PAUL ERICSEN :. Il)
(eDr- 7bloyisnL) Q �736g . G NSEb DE IGIVEp 1
EXP1' S I 111
PHONE Area Code( r,.06 ) S -- k 3 I 11-4,-0 L
SYSTEM DESIGNER P)C411t, £Ii C .e v1
LEGAL DESCRIPTION: Section 13 Township 34 Al Range o2 tiu PARCEL# q' e I on 43$
Subdivision Name e £ 49f < Ctrl bvt,t,\ Division a- Block 4 Lot(s) 3g
SITE LOCATION 411 3 wyl S• "$■a, part Yd ui✓I S-Gra_ I 14 , Zip Code q8'36 S
SOURCE OF SEWAGE: Residential X Residential ADU Commercial Community
TYPE OF WORK: New _ Redesign Upgrade Repair Partial(tank) ki (drainfield)
Expansion Designate Reserve Area Modification
Conventional Alternative Drainfield Length ft. Trench Width ft.
Number of Gallons/day 24b Trench/Bed Depth in. Number of Lines
Site Size 100 ),I`511 Septic Tank size gal. Pump Chamber size gal.
Water Source: private public s Soil type (ATTACH SOIL EVAL.)
Previous eval: 6) / no # 1-12 Application Rate gal./sq.ft./day
TYPE OF SYSTEM 6.re,U jeki C:flet Viv1 o v1a
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,'easonable 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 it's employees,representatives or agents for the purpose
of application review and any required later inspections. Access and right of entry to the applicant's property or structure shall be
requested and shall occur during regular business hours.
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 application will •- separately judged by the rules and laws in effect at that time.
•
.- .. :/A_ . /1- 2g-o 6,
Owner Signature Date
FOR OFFICE USE ONLY 2f,,C�r `� - 1, v� C r\ 1 d .
PARTIAL ASBUILT FINAL J%�i I,-i •
APPROVED
PRESS/TEST PUD Q 4,t,-
Fire District ((�� Planning District �}/ p r7 School District ��7 Zones/
Date CL Fee t''1 I Rec# a Ip Os / Check# IO2 .. Case#SEP D(0 40
�G - 1///- 'mss T .41M � 777 A/'7 .
Septic Permit Application Form_05-10-04_pclf ��
g' 14112-' - 0-77 - 77iltli ,Z?�-Y-A7AS IA/ Lam.. Alb
To- Jefferson County Environmental Health(Randy Marx)
Fm- Enviro Check, LLC
Date- 121106
SEP 71-12
APN- 938100438
Address- 411 Sunset, Port Townsend
On 110306 Enviro Check, LLC performed an EES Inspection. The septic
tank inlet baffle lid was removed(3 ft. depth from grade and under concrete
porch). The outlet baffle was checked using a flashlight and mirror vs
unearthing outlet baffle lid, as there was not permission to remove lawn
irrigation piping and wiring. The effluent level at concrete baffle appeared to
be about 1 inch below the bottom of the concrete baffle. That would mean
the effluent level would be well below the outlet pipe area. The report
reflected that the tank needed repair as it was probably leaking.
On 121106 I met with Tim Thomas Jr. from Bernt Ericsen Excavating. He
told me they had water tested the tank and it was holding water. They had
removed the lawn watering system piping and wiring and unearthed the
outlet baffle lid. Looking at the outlet baffle it was revealed that what I had
been looking at was a deteriorated mortar section between two separate
concrete sections that make up the concrete baffle (where I had seen level).
Given this the septic tank integrity appears good at this time.
Dale Wurtsmith
Enviro Check, LLC
;,CN Grp, JEFFERSON COUNTY PUBLIC HEALTH
�C3 615 Sheridan Street • Port Townsend •Washington • 98368
X59;A �
www.jeffersoncountypublichealth.org
November 28, 2006
Richard Arthur
5011 37th Ave Nt%
Seattle,WA 98105
RE: Evaluation of existing septic system
411 Sunset Blvd, Port Townsend
SEP71-12,Septic System Corrections Required
Dear Richard Arthur:
An evaluation of the existing sewage-disposal system (EES)was completed on November 3,2006 by
Dale Wurtsmith. This inspection found that the effluent level in the septic tank was a foot below
the outlet pipe,indicating that the tank may be leaking. The inspection also found a concrete
porch/steps over the tank. Correction of these items are required.
This letter is intended to serve as formal notice that no further approvals shall be granted until the
corrections are completed and inspected by Health Department staff or a licensed septic designer:
• A licensed septic designer must evaluate the septic tank for repair. A permit is required for
any repair or modification of an onsite sewage system, per Washington Administrative Code
246-272 and Jefferson County Code 8.15.
• No building is allowed over any portion of a septic system, per Washington Administrative
Code 246-272. Please remove the steps over the septic tank.
A list of licensed septic designers has been included with this letter. If you have further questions
please contact this office at 385-9444.
Sincerely .U.S, Postal Service,.
CERTIFIED MAILTM RECEIPT
t- / r�tl (Domestic Mail Only;No Insurance Coverage Provided)
r
/1 cl For delivery information visit our website at www.usps.com,
Daniel Nidzgorski
Environmental Health Specialist .' Postage $
J3 Certified Fee
O
cc: Dale Wurtsmith
,_,C) Receipt Fee Postmark
0 (Endorsement Required) Here
O Restricted Delivery Fee
O (Endorsement Required) t if 2 $ 0414
r1
Q Total Postage&Fees
...0 Sent To
o Ar -c 71- i
r-- Street,Apt.No.; y`
or PO Box No.
City,State,ZIP+4
PUBLIC h t PS Form 3800,June 2002 See Reverse for Instructions
COMMUNITY HEALTH - " . : .
DEVELOPMENTAL DISABILITIES ALWAYS WORKING FOR A SAFER AND NATURAL RESOURCES
MAIN:360-385-9400 MAIN 360-385-9444
FAX 360-385-9401 HEALTHIER COMMUNITY FAX 360-385-9401
r
Jefferson County Department of Community Development Office Use Only 174
621 Sheridan St., Port Townsend WA 98368 (360) 379-4450 Date
Evaluation of an Existing Onsite Sewage System (EES) Fee 3�
Recpt
Draw on the back of this sheet a current plot plan showing location of: Check '1-7b3
Buildings, Drainfields, Septic Tanks, Wells, etc OR attach a current plot plan case# 1'1').
identifying these items.
ALL SPACES MUST BE FILLED IN.
If information is not available enter (NV) or not applicable (NA). RECEIVED A
Type of Evaluation Reason for Evaluation
❑ Routine Operation and Monitoring InspeNa 0 3
Evaluation of on-site sewage system a Real Estate transaction
LI Evaluation of drinking water ❑ Complete a Permit # IF1 t RIN I: NIV fin
W
❑ Building Permit Review and/or no septic permit on We fin
❑ Evaluation of on-site sewage&drinking water ❑ Other, explain
Date of evaluation \\ID— 0(o Inspected by P`" Wt t (Envirocheck, Lig
Tax Parcel # q3g\oo013'b Permitted System )( yes no Permit/case # SEP —( t—\a
Su division, Division, Block and Lot(s) Cg4E C..,Eop.G'E Co�Nn�V�Blk �T 3c3
Lot Siz Acres or Dimensions U`f1'X \5C)**(
Current Owner .st.c\-\ksko
Site Address 1-k-\\
Owner Phone #
Previous property owner name(s) - (NN if not known) \-\,l_ 1.-YEA1-%9c)(k
Directions to Site -.(Nr‘ W\g, * K. KGs kVE. , ( €
Date System Installed k Age of Dwelling \1(.3 # Bedrooms a
House Occupied yes )c no, vacant how long?&e.. AS ■Or-AL, oNLj
Who installed system?
Send completed report to:
Owner
Name V,; Cc
Mailing Address 5o\\ � � k*' E s \U..)A.9 3loS
'Eh°r- 'email/fax g.v(o- �S- z ( - \\04QL E).1\,ARe,o\€(.\
Realtor or Other Representative
Name
Mailing Address
Phone/email/fax
f
r
Include the following items on your plot plan:
❑ Property boundaries ❑ Wells E
❑ Names of adjacent streets ❑ Septic tank CER 9
❑ Driveways and parking spaces ❑ Drainfield (enter NN if unkrNtiv) 3 ,+11 t
❑ Surface water(ponds,creeks, etc) ❑ North Arrow V
❑ Buildings(residence, sheds,garages, etc) *Mtn 1 lfliNTV 0('11
PLOT PLAN-date prepared \\x3000
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t.z Et trea7a.� /w,, V-%-,,y !// II II[I ( ,,,( (/i /
a = b9AINF!ELD AREA
DEFER to P `- /
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NOT TO SCALE
ENVIR HECK, L.L.C.
1612 Hastings Ave.W.
Port Townsend, WA 98368
\--,.........._
Permit#or Parcel# 'SE �( `—
Evaluation of an Existing O site Sewage System 7,',; !r 4_pat = _
a
Date of Inspection \\(J3O(o Inspected by D WUrtglnith (Elwin)Check' l C)
Water Supply (fill in only if water supply is being tested in this evaluation)
Sample was taken Yes No Sample Results RECEIVI4j)
Well casing 12" above ground Yes No
Sanitary Seal in place Yes No N3V 0 a .4'il e
Public: offsite onsite Name of System
Individual: offsite onsite
Is well more than 100' to drainfield/disposal component _y es_ no, if ffig MIM.1111IVi11 E11
Is well more than 50' to tanks and effluent transport line_yes_ no, if not, distance
ONSITE SEWAGE SYSTEM
# Bedrooms/gallons per day indicated in County Health Dept. records for this case a\a,4o
#1 - Septic Tank
Tank size ---/S011 gal. 'C single compartment two compartment ce.yNRQE- material
Riser to grade on inlet ( yes )X no. Riser to grade on outlet yes )C no
Condition of tank good K needs repair, describe E �nM m�OT3
1st comp. Scum (top layer) O in. sludge(bottom layer) \\ in.
2nd comp. scum in. sludge in.
Was ground water observed leaking into tank? yes )< no
If yes,where was water observed?
Condition of baffles: Inlet: X_ good needs repair material (PVC, oncre
Outlet: )c, good needs repair material (PVC,'oncrete
Screened Outlet no yes, condition clean clogged/dirty
Septic tank needs to be pumped (per Jefferson County code 8.15.150 (1) (b)) yes X no
Effluent level at outlet(mark level on circle)
If effluent is below the outlet, indicate
when tank was last pumped:
1;-\
Does system include a pump? yes If yes, complete the next section no (if no skip to section 3)
#2 - Pump Chamber
Tank size gal. Material. Riser to grade? yes no
Condition of tank good needs repair, describe
Solids in Tank(see 8.15.150) yes no scum in. sludge in.
Was Ground water observed leaking into tank? yes no
If yes,where was water observed?
Screen around pump? no yes, condition clean dirty/clogged
Shroud around pump? no yes
Electrical Components
Pump operating yes no, describe
High water alarm functions yes no, if no, describe
Elec. Panel condition good needs repair, describe
Pump cycle drawdown inches. Time for pump cycle min/sec.
Timer Settings min/sec on min/hrs off Floats secured: yes no
Permit#or Parcel# pp 1—to
Evaluation of an Existing O?isite Sewage System c;
'
#3 — Drainfield •
Appropriate Vegetation in area x yes no. Describe vegetation 1 S
Indications of surfacing sewage (check one) yes , if yes, describe and diagram on plot plan
k no
drainfield area is overgrown and not observable
Signs of parking/driving in area yes IC no drainfield area unknown
Ground settling or erosion yes X no overgrown/not observable
Monitoring Port Observations (if present):
Residual Head yes, #of inches no
Ponding in trench yes, #of inches of ponded effluent no
Repair area is? Available as shown on permit >C. None evaluated or show •1 cerilitoE�( f h
Addendum (page 5) is attached for evaluation of Treatment Unit or detailed evaluation of dr:1'\i�(+ i1 JJ�� If D V'/
yes x no
NOV Q 3 Allite;
COMMENTS (attach additional sheet if necessary):
JEREMEINN WOW In
#1-A. Risers are mandatory on next inspection.
B THE E� -LLE L \- A 1a" vs-cc-LET ye.
s A \) 4'%e.Atto,a o'F f\ ALE Jn.
C. st i s A Hach Coae(L 9Dctt..k\(swv-,) T1\E To? of
Ss�f'i��►�k.
ft,V1ot-l \---‘a� of \\JoSmQ Vto■S LAYE.Rs OMEN AMY ?e,rn<44
of 5EwAGE ;\isVefi
3--pt• --'S W/ \.o E3E }-oTtb n-r-N•\\E- R ■\T EKE I o. M9
ow.�eR. t-s�AlI.EO # c Coo-Q- O 1,y‘T nr., Nt-No " 4Nanot41k*4 l4T• ►ME
EE Qoo s-iTy F, s� -i 1- cam, mn .iu aRmlrtaN
ether(A) The house/dweHin was u °' '�sr M' E �'`"�`o-
g noccupied so no o f ®R.A\ s v N k ,,,N
assessment of drainfield could be made.
SEE ATTACHED ADDENDUM
Was a System Problem Identified?Yes X if yes,what section#.__\( o
This report on the existing onsite sewage system is valid for the permitted or historic(if installed prior to permit
requirements) use of the system only and does not constitute assurance of future County approvals (such as building
permits)on this parcel. Any future application will be judged separately by the rules and laws in effect at that time.
I certify that the information provided is based on a review of County records and my direct observations at the time of
inspection.
WZdwo
Name/Signa ure Date
No guarantee of future onsite sewage system performance is implied or granted based on the information contained in
this report. This report constitutes a summary of findings only.
Permit#or Parcel# SF p \ �,
Evaluation of an Existing Onsite Sewage System._0'/30/04_pd
DATE, \k\n3�
ADDEl� ADDRESS �Fl► �,�s i aWD.
Enviro Check,L.L.C. Company Disclaimer
Based on what we were able to observe and our experience with on-site wastewater technology,we submit
this Sewage treatment Inspection/Evaluation Report based on the present condition of the on-site sewage
treatment system.Enviro Check,L.L.C.has not been retained to warrant, guarantee,or certify the proper
functioning of the system for any period of time in the present or future.Because of the numerous factors
(usage,soil characteristics,previous failures,etc.)which may affect the proper operation of a septic system,
as well as the inability of our company to supervise or monitor the use or none visible areas of the system,
this report shall not be construed as a warranty by our company that the system will function properly for
any particular buyer or owner.Enviro Check,L.L.C. disclaims any warranty, either expressed or implied,
arising from the inspection/evaluation of the septic system or this report/evaluation.We are also not
ascertaining the impact the system is having on the groundwater or environment.
Enviro Check,L.L.C. does not make any claim,warranty or guarantee as to where property lines/boundaries
of properties are located.And does not warrant or guarantee any encroachments from on site sewage
systems on to adjacent properties.Any indications of possible property lines/boundaries are approximations
and do not indicate legal property lines or boundaries.
Enviro Check,L.L.C.will not be held responsible in any way for information being undisclosed
(intentionally or unintentionally)by property owner,representative or other parties of interest.
All reports,including E.E.S. inspection reports are subject to any change by Jefferson County
Environmental Health Department.Enviro Check,LLC is not liable for any such changes.
All parties are encourages to check county records for any information regarding properties. J ,r 11
Company
NOV 0 3 Ali
Enviro Check,L.L.C.
1612 Hastings Ave. W JEFF IINIMINIY or
Port Townsend,Wa.98368 Lrrt J(� !V
360-379-9400
I acknowledge that I have studied the information contained herein and that my assessment is honest,done
in accordance with Jefferson County Ordinances, and to the best of my ability,correct.
Dale R.Wurtsmith Co-Manage
SAMPLING (Septic tank) MEASUREMENTS
Date- Counter Setting-
PH Result- Hour Meter-
DO Result-
Temp.Result-
-r �T sl :7I'' ool 1 URL3 IS54
7-i
,East Caroline QLYIlPIC HEALTH DISTRICT Permit Now _`3 ..
;, A, Angel Fee Paid $ 0
SEWAGE DISPOSAL PERMIT APPLICATION
Submit in Duplicate
PbclzDY; ,
4:0, 4 ''' "4 ADDRESS .-5 ,fie eia /.30-i. re DAT _ _i
,LEGAL DESCRIPTION \ 3 \v \ ` PHONE
DIRECTIONS ..FOR LOCATING SITE, C
.'.)&. (LI I i 41,61,41//k de0-62 -, ' _____-----
APPLICATION IS HEREBY MADE TO: INSTAL4 NEW SYSTEM REPAIR EXISTING SYSTEM.L.
.51/4 -.4?_-.� • 2 \ r '1004 /-50 S L-V.
'YPE OF BUILDING NO, or BEDROOMS BASEMENT ;SITEE .SIZE RAMS OF INSTALLER
-----arfErMRSrSIbE, DRAW A DETAI
50-Pr w` N TV!NG .i�t ) ING FORM TTY'. ;,�
2.,_-Proatiott of a 7. Driveways,. patios. carport. etc. - U
__ Streams or bodies of water nearby
�dR6•-�.�_ y
5.._Location: of septic task 9. Location of percolation test holes
4,,..Lo ation of drainfiel,d 10. Septic tank Size .7c °-exsS f-,
5, dope of land 11. Length of proposed drainfield
6,-Water lines & well(if applicable) 12. Depth to water if encountered.
PERCOLATION TEST RESULTS ..--,
' =1) . me require. to . *erQolation rate ' ype o so C.
of hole Seep last 6 in. (divide time by Q - --,
Pere. No. 1 ix C
Pere.. No. 2 - - -
Perc. No. 3. ' _ .
DRAINFIELD LENGTH /?-01
WIDTH i DEPT. N @. OF LINES �-,.
IT-IS- HEREBY
Ntk,ED HAT THE PROPOSE a INS , -4 ;T 0' I L BE MADE IN ' .e. MANNER v
AS-DESIGNED AND APPROVED ON THIS APPLICATION. '
• / / ' 7
Ili' 4. '�.._ �.v4Li
a of ppzc;vr
.APPROX. DATE OF INSTALLATION S•e-GA .
SANITARIAN'S COMMENTS: w,.‘\5 `.�` k•A., \ k c. v..._c e� � j\ 'N' '\.5
0
1
_CO' S /TUT S A P- p WEE, Two-7. . -' S GNATURE APP-AR AS APPO T, -IZ
W
PLAN APPROVED DISAPPROVED DATE CO
DATE-.,..sp� . ... _�.�._. ...�.._._a-_� ._.___
REMARKS: ' .,.. s\5 ,--, ' \\-�.. v C- ? , cL/Y 7 r
I CERTIFY THAT THIS sYsTai WAS INSTALLED IN THE MANNER APPROVED BY THE HE„i LTL
DEPARTMENT.
INSTALLER'S NAME DATE
5.-48