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44 Jefferson County Department of Community Development �'�"'. 0 0
r/2 621 Sheridan St.,Port Townsend WA 98368,(360)379-4450 ��.!' ( -1�
`r<6i SEPTIC PERMIT APPUCATION I ' - - �,ek.4,•
PROPERTY OWNER 4 IV S 4 -6 A�bAKA I C ,{- , ' �, I
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MAILING ADDRESS , i 4 E. 1 • .,1 :. L ER ICSEN--- `)
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PHONE I ) 3_y -I,1-
sYsTEM DESIGNER ER 1 t...5 EN DES 1E7N Designer Phone# O176779000013/, 3 O - d f 6 3 4
LEGAL DESCRIP1 ONl: Section I Tow ZEN_ Range 1W PARCEL#
Subdivision Name 'i .LAS i_E ..E 1 Division Block Lot(s) 23
site address/Directions tosite It, ED61EWATTr 'POET H AtLO Cis , AtJA 61 8339
SOURCE OF SEWAGEIUSE TYPE OF WORK WATER SOURCE
Residential '1( New Tank/s only Private
Residential ADU Modification Public`PUb
Commercial Expansion
Community Upgrade
Repair SITE SIZE :AO Aug
SYSTEM TYPE Partial Repair-(tank) (drainfield) Previous Evaluation
Conventional Designate Reserve Area Yes# 13- 1 aid ' ux S i-`�1
Redesign )( No - car ,+ �;
SYSTEM DETAILS
Number of Gallons/day cvio Soil type (attach soil eva1.) Application Rate gat./sq.ft./day
Drainfield Length ft. Trench Width ft_ Trench/Bed Depth in_ CC
Septic Tank size I 0 0 0 gal. Pump Chamber size gal- '1 i''(�S —0 'Q` '5 PA e J S
TYPEofsystem TANK 4 eiRAWiTY PI � TO (aOMMu N r rr SYSTEM
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 1 further agree to save, indemnify and hold harmless Jefferson
County against all liabilities,judgments,court costs,reasonable attomey'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. Staffs access and right of entry will be assumed unless the
applicant informs the County in writing at the lime 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 application will be separately judged by the rules and laws in effect at that time.
Property Owner Signature Date
FOR OFFiCE USE ONLY
PARTIAL ASBUILT 012.1W/ G /
FINAL • / ,
APPROVE
INSP/PUMP TEST P.,U L0\46-
ALL HOLD REQ.MET Cg- ily, 6014 #5L LOSS b/q11,��
D a t e /c/i H Fee /Z /= Rec# /L/7799 Check# //'7 r Case#SEP 1 J —OO 13 Lo
H:\WEB\PDFs\Septic\septic_permitapp_2008.DOC
�` JEFFERSON COUNTY PUBLIC HEALTH
615 Sheridan Street•Port Townsend•Washington •98368
www.jefferson countyp ub lichealth.o rg
1-none 36U-3bb-9444 Fax 3bU-3(9-44tf I
ON-SITE SEWAGE DISPOSAL PERMIT
PERMIT #: SEP13-00136 Date Received: 12/11/13
SITE ADDRESS: 76 EDGEWATER CT Date Issued: 03/13/14
Date Expires: 03/13/17
APPLICANT: HANS KNIGGE PHONE:
BARBARA KNIGGE
4315 201ST AVE NE
SAMMAMISH WA 980746120
LEGAL DESCRIPTION: VILLAS BY THE SEA LOT 23
PARCEL#: 997900023 Section: 1 Township: 29N Ranqe: 01 W
DESIGNER: BERNT ERICSEN PHONE: 360-301-0324
293 PINECREST DRIVE
PORT TOWNSEND WA 98368
SYSTEM DESCRIPTION: SEPTIC TANK TO COM SYS
No. of Gallons per Day: 240 Type of work: NEW
Drainfield Trench Septic Tank
Length: feet Width: feet Depth: inches Size: 1,000 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.
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.: SEP13-00136
1.) No portion of the sewge transport line may pass through the proposed rain garden.
2.) Villas By The Sea Plat denotes a 50-foot shoreline setback from the top of the bluff. No land
disturbing activities will be allowed waterward of the Shoreline setback.
3.) Final approval of the sewage disposal permit will be given at the time our office has written
notification by the PUD and/or the designer that inspections have been made and the installation
meets their satisfaction.
4.) This system must be constructed by an installer certified by the Jefferson County Public Health
Department per state code WAC246-272A-0250.
5.) Septic tank and pump chamber to be water tight. Extra protection (i.e. Bentonite) to be used
around inlet, outlet, and risers due to high water table.
6.) 10' separation required between a Water line and all portions of the onsite sewage system; effluent
transport line, tanks, treatment and disposal components.
7.) H - AS PER WAC 246-272AAND JEFFERSON COUNTY CODE 8.15 ALL ONSITE SEWAGE
SYSTEMS REQUIRE THATA 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
8.) 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.
9.) Notification of the start of construction shall be faxed or emailed to Jefferson County Public Health
ONE WORKING DAY prior to start.
10.) H -An asbuilt drawing and certification of completion by the Designer is required prior to final
approval.
11.) 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.
12.) Divert all sources of drainage, including roof drains away from septic tank and drainfield area.
13.) The site plan as submitted with the Septic Tank to Community System application on December 11,
2013 has been reviewed for consistency under the UDC, and has been approved by Jefferson
County Department of Community Development. Any modifications, changes, and/or additions to
the stamped, approved site plan dated December 30, 2013 shall be resubmitted for review and
approval by Jefferson County Department of Community Development.
14.) This approval is for a Septic Tank to Community System only. Any future permits on this site are
subject to review for consistency with applicable codes and ordinances and does not preclude
review and conditions which may be placed on future permits.
15.) The area in which the site is located is listed on the Washington Heritage Register for"Cultural
Resources of Hadlock Bay". In the event archaeological items are discovered, the proponent, the
land owner, or contractor shall observe the protocol developed by a professional archaeologist in
conjunction with local Native American tribes as follows: Stop work; notify immediately the Director
of Community Development (360) 379-4450 who will immediately notify the State Department of
Archaeology and Historic Preservation (DAHP); protect the area; obtain services of a qualified
archaeologist; and, if necessary, obtain appropriate permit from DAHP.
SEP13-00136 Page 2 of 3
\\tidemark\data\forms\F_SEP_Permitmod.rpt 3/13/2014
16.) VOLUNTARY MEASURES OF COASTAL &AT RISK SIPZ:
1. Installation of a flow meter.
2. On-going well monitoring for chloride concentration.
3. Submittal of monitoring data to County.
17.) The parcel is located within a coastal SIPZ (seawater intrusion protection zone) according to the
County GIS map. There are voluntary and mandatory measures identified in the Jefferson County
Seawater Intrusion Policy (Resolution 44-22, effective September 23, 2002) that apply to well
drilling proposals and building permit applications on existing lots of record.
A Coastal SIPZ is defined as: all islands and area within one-quarter mile of marine shoreline, but
no history of chloride concentration above 100 mg/L in groundwater sources within 1000 feet.
18.) 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.
19.) 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.
20.) This parcel is within the Chimacum-Hadlock no shooting area per JCC 8.50.
21.) This project reviewed and approved as a Shoreline Exemption under JCC 18.25.090 (5).
22.) 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.
23.) 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.
SEP13-00136 Page 3 of 3
\\tidemark\data\forms\F_SEP_Permitmod.rpt
3/13/2014
p . CONVENTIONAL SYSTEM ASBUILT INSPECTION REPORT
INSTALLER I`1 a e-I-I iP1 K attyt PARCEL# gg7c 000
Permit Owner 1-10$'5 h nL�g e, Permit # 6.941 13— 3 to
ABSORPTION AREA:
DRAINFIELD TRENCH TRENCH TANK #OF #GAL! [�
LENGTH --' WIDTH DEPTH SIZE I Qb BEDRMS of DAY cite)
Tank Shroud!
IF PUMP AND PUMP CHAMBER REQUIRED: Size Screen
Float Arrangement
High water float—distance to top of tank/emergency storage —
Dose drawdown (#of inches) #Gallons/Dose —
Timer/Dose Counter info Pump Size!Manufacturer
I CERTIFY THIS ONSITE SEWAGE SYSTEM AS INSTALLED AS DESIGNED,PER PLAN APPROVED
5- r3-t`{- l5 t' a7-/A
DATE APPROVED Di S,5Ace SIGNATURE DATE
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al to existing stub out were installed Measurements: ‘-c ,..'"
A and backfilled prior to designer A to C= 14'3"
ct■ being notified. Routes are as A to D= 18'
described by installer(Marty B to C= 14'
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Approximate location of existing
water and sewer lines as shown
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to edge of pavement(verified by Bernt Ericsen )
to depth of 5'.Appears to be under pavement as shown
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(Located 2-27-2014 and (Top of neighbors meter
verified by Bemt Ericsen) box is"Bench Mark")
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to depth of 5'.Appears to be under pavement as shown
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Approximate location of existing 9 V3'lv\VP
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FINISH GRADE 24'0 RISERS IWIH LIDS NA77YE FILL e?co)---
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PENINSULA TANKS
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NOT TO YG i uY.1
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1 ,i ,,P IN =- / BACKFILL AROUND
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COMPARTMENT -VERGED I BLOCONC ,i
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P4�t V? e 997900023 �; : �
as, B VT PAUL ERSEN%.-44
Project Description: 's ,e7'I
Install Septic Tank and gravity pipe (ASTM 3034 ) to existing stubout ( location 3-�-1.
verified ). s Plot?tan
Septic Tank:
Two compartment mono — pour concrete ( 1000 Gal. ) equipped with water and
airtight unvented risers to grade. Tank shall be water tight. Fill tank with water
after placement, to be observed by Designer. Tank to be set on 6" of pea gravel.
An outlet baffle filter is required in the septic tank. Use Orenco FTiPW 0418 - W
or equivalent, to be approved by Designer.
Gravity Pipe
Gravity pipe from house to septic tank to be ASTM 3034 installed @2%
minimum. From septic tank to existing stubout ( location verified ) @ 1%
minimum.
Water Line
Install water line from meter to house. Maintain a minimum of 10' between water
line and septic tank / sewer lines.
•
Inspections
Contractor to contact designer prior to construction to set up pre-construction
meeting, and inspection schedule.
General Construction Notes 1. The work described herein consists of
construction of an on-site wastewater system.
2. The contractor shall be knowledgeable and experienced in the
construction of this type of wastewater system and shall hold a valid certificate
from Jefferson County Division of Environmental Health.
3. If during the installation of the system the contractor finds soil conditions
that may lead to premature failure of the system, construction shall be
terminated immediately and the designer notified. Such soil conditions may
include groundwater, fill, clay, highly compacted soil, bedrock or excessively
permeable soils.
1. Any inconsistencies, errors, or omissions that, in the opinion of the
installer, would compromise the quality of the wastewater system shall be
reported to the designer prior to construction.
1. Transport pipe and laterals shall be Schedule 40 PVC, unless otherwise
stated in design, solvent welded joints. All fittings shall be Schedule 40. All
transport pipe in traffic areas shall be Schedule 40. Backfill in traffic areas shall
be pitrun gravel and compacted. All gravity pipe shall conform to ASTM D 3034.
All gravity and transport pipe shall be bedded, using native or imported material
free of rocks, debris and sharp objects. Double case in traffic areas as described
in plans.
2. All exposed soil shall be seeded and mulched prior to the final inspection.
Seed shall be spread at an approximate rate of 10 lbs. per 5,000 sq. ft.
3. The installer shall be responsible for constructing the system according to
plans and conditions of permit and shall be responsible for its proper operation
and function for one year. The owner shall be responsible for operating and
maintaining the wastewater system in accordance with WAC 246-272A-15501.
4_ Any changes, substitutions, or deviation from these plans shall be
approved by the designer and by the Jefferson County Environmental Health
Department.
5. The installer shall grade to divert all surface water runoff away from tanks
and drainfield/reserve areas.
6. The bottom of the trench or bed may be inspected by the designer prior to
placing sand fill or drain rock and shall not exceed +/- i/z" from level.
7. Notify designer 48 hrs. prior to pressure test, after permanent power has
been connected to panel and L. and 1. inspection complete. Any deletions from
plans, or necessary adjustments, shall be completed by installer.
8. Setbacks to all known water lines.shall be a minimum of 10'. No crossing
of water lines with any septic component shall be allowed, except as included in
septic design approved by Jefferson County Health Department.
9. Setback from the building foundation wall shall be 10' minimum to
drainfield, 5' minimum to tanks and 2' minimum to non-perforated
sewer pipes.
10. Setback from property lines, easements lines, and driveways shall be a
minimum of 5', for both drainfield and reserve areas.
11. Water saving appliances, fixtures, and practices are to be used.
12. The septic and pump tanks, drainfield and reserve areas are to be
protected from vehicular traffic or mechanical disturbance.
13. The installer is to verify pump requirements at the time of installation.
14. The designer is to provide the " Record Drawing " and letter of
certification.
15. This system has been designed in accordance with WAC 246-272 A and
the most current Department of Health "Recommended Standards and
Guidelines for Pressure Distribution Systems," and has been approved by the
Jefferson County Health Department. Nevertheless, negligence or improper
action on the part of the users could result in the premature failure or
malfunction of the system or its components.