HomeMy WebLinkAboutSEP2014-00004 Jefferson County Department of Community Development
621 Sheridan St.,Port Townsend WA 98368,(360)379-4450
SEPTIC PERMIT APPLICATION
PROPERTY OWNER MAREK& MAUREEN WALIGORA
MAILING ADDRESS 13806 SE 36TH STREET
VANCOUVER, WA 98683
PHONE ( 503 ) 932-0274
SYSTEM DESIGNER NATHAN N. CLEAVER Designer Phone# 360,-598-6546
LEGAL DESCRIPTION: Section 17 Township 29N Range 1 W PARCEL# 901-172-004
Subdivision Name Division Block Lot(s) A
Site address/Directions to site 3221 STATE ROUTE 20, PORT TOWNSEND
SOURCE OF SEJNAGE/USE TYPE OF IVORK
Residential d New d Tank/s only WATER SOURCE
Residential ADU Modification Private d
Commercial Expansion Public
Community Upgrade
SYSTEM TYPE Repair
SITE SIZE 270,507+/-
Conventional / Partial Repair-(tank) (drainfield) Previous, .al ti n
Alternative o
Conventional
V Designate Reserve Area Yes#ZUNUU-U0'111.
Redesign No
SYSTEM DETAILS
Number of Gallons/day 360 Soil 5
type (attach soil eval.) Application Rate 0'4 gal./sq.ft./day
Drainfield Length 300 ft. Trench Width 3 ft. Trench/Bed Depth 12 in.
Septic Tank size 1,000 gal. Pump Chamber size 1,000 gal.
TYPE of system SIMPLE PRESSURE DISTRIBUTION
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,reasonable attorneys fees and expenses whidh'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 time 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 on
NOT assure you of any other County approvals. For example, it D� S se wage s�rANcE�OES
you will later obtain permission to build a permanent residence or other structure onft� � that
future application will be separately judged by the rules an* laws in effect at that time.
16 ( li %
•perty Owner rgnature 4, D to
// FOR OFFICE USE ONLY
PARTIAL
A"ROVED ASBUILT - FINAL,r1J If f o// .
INSP/PUMP TEST tJ t V15 PUD
ALL HOLD REQ.MET /'r
Date I /(( I I y Feet{,(['8,Lt , Rec# i L)(c —i Check# 1 4ci S
I I tl i L (.0„y 1,1 Case#SEP �r-C�CI O D�
H:\WEB\PDFs\Septic\septic_permitapp_2008.DOC
,' JEFFERSON COUNTY PUBLIC HEALTH
615 Sheridan Street • Port Townsend•Washington •98368
www.jeffersoncountypublichealth.org
Phone 3b0-Mb-9444 Fax 3E6U-3(9-446 I
ON-SITE SEWAGE DISPOSAL PERMIT
PERMIT #: SEP14-00004 Date Received: 01/06/14
Date Issued: 04/16/14
SITE ADDRESS: 3221 SR 20 Date Expires: 04/16/17
PORT TOWNSEND, WA 98368
APPLICANT: MAREK WALIGORA PHONE:
• MAUREEN WALIGORA
13806 SE 36TH ST
VANCOUVER WA 98683-7700
LEGAL DESCRIPTION: S17 T29N R1W TAX 20 BLA#113811 V35/P124
PARCEL#: 901172004 Section: 17 Township: 29N Range: 01 W
DESIGNER: NATHAN CLEAVER PHONE: 360-598-6546
NATHAN CLEAVER SEPTIC DESIGN
1990 KIMBALL ST. NW
POULSBO WA 98370
• SYSTEM DESCRIPTION: PRESSURIZED TRENCH
No. of Gallons per Day: 360 Type of work: NEW
Drainfield Trench Septic Tank
Length: 300 feet Width: 3 feet Depth: 12 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 all phases of construction
HEALTH DEPARTMENT MUST BE CONTACTED FOR FINAL INSPECTION.
SPECIAL CONDITIONS APPLY - SEE ADDITIONAL PAGES
Q nn,�Q • 944
CONDITIONS OF APPROVAL - PERMIT NO.: SEP14-00004 � 2 11A 46.
�
1.) Setback to surface waters 50' required from tanks. '^^" J
tfif-)
2. MAXIMUM TRENCH DEPTH 12 INCHES
otAseA-
3.) The sewage transport line must be installed in a trench at a depth that will protect from freezing as
this line is designed to remain full between doses to the drainfield.
4.) The primary and reserve drainfield areas are adjacent to an approved easement area that benifits
other properties. A 5' setback must be maintained as per design
5.) 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.
6.) H - AS PER WAC 246-272AAND JEFFERSON COUNTY CODE 8.15 ALL ONSITE SEWAGE
SYSTEMS REQUIRE THAT A 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
7.) Health Dept. required to observe pressure test with system designer when system fully
installed/complete, 48 hours notice to be provided for scheduling.
8.) This system must be constructed by an installer certified by the Jefferson County Public Health
Department per state code WAC246-272A-0250.
9.) 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.
10.) Notification of the start of construction shall be faxed or emailed to Jefferson County Public Health
ONE WORKING DAY prior to start.
11.) H -An asbuilt drawing and certification of completion by the designer is required prior to final
approval.
12.) Compliance with the conditions of the Site Plan Approval Advance Determination is required.
13.) 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.
14.) 10' separation required between a Water line and all portions of the onsite sewage system; effluent
transport line, tanks, treatment and disposal components.
15.) Contact designer prior to installation for staking of drainfield area.
16.) Divert all sources of drainage, including roof drains away from septic tank and drainfield area.
17.) This application reviewed and approved for a on-site septic system and single family residence
under JCC 18.25.090(5).
18.) 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.
SEP14-00004 Page 2 of 3
\\tidemark\data\forms\F_SEP_Permitmod.rpt 4/16/2014
19.) 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.
20.) 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.
21.) This system as designed and approved is sized for only one single family residence. It is not sized
for an Accessory Dwelling Unit (ADU). The minimum daily design flow per residence is 240 GPD.
SEP14-00004 Page 3 of 3
\\tidemark\data\forms\F_SE P_Perm itmod.rpt 4/16/2014
JEFFERSON COUNTY PUBLIC HEALTH. 615 SHERIDAN, PORT TOWNSEND WA 98368
ASBUILT INSPECTION REPORT For RECORD DRAWING
Designer NATIFAW N. C FP, Permit # SEP (4--0O004
Installer �C6N Jor'E - Ne.Sv . y��i c_.cApf ,Parcel # Q Ot —1I-2—OU'-i-
. Electrician AArtA1.1 MO- NS'ES Design Flow WOO
Property Owner M16110- i PAAVReeN Vv -`G
Site Address 3224 s--t-ATs« 20 , PortrI-Ovui,6 1,t®
Answer all questions or indicate NA
DATE
Tanks.` Pumps and Controls INSP.
Tank (manufacturer, size, baffles) rtA4,G12.MAN 1 1AtO qzriVon1 j 2-cow1.e• let 5Pfor WO
Pump chamber (manufacturer, size) t t GtL.1M.A►.3 / 1 tC,7PV GA t.to.s lg-S '2Al'}
. Screen(s)and/or Pump Shroud (type, location) D/2E/VCo 71, 777-E DvTZ.er 2k,serzottlf
ilt
Were Tanks tested onsite for water tightness? Yes / No ��l`
Panel Model O is CO Timer Model M V 1,p
-S 1/2,prn 9Jt/AI irn
Pump 1 - Man./Model OntICo /K56011 Flow Rate 22.45 qpm e1J °/S
Pump Location (i.e. garage, treatment unit, basement) p 9'C-gt.1‘r-...
Float/transducer settings Inches Timer
from bottom of tank- On/off- 2.0 in. Functions: On Li 5 0min
Veto - % in. Off- 90 sec/0hr
Alarm - __ in. Veto On - 14A sec/min
Storage Above High Water Alarm 31o0 gal. Veto Off- NR sec/min/hr
Dose Counter Reading 12- # gallons/dose k(Q•$3S gal.
Elap. Time Meter Reading OhrA)nupJ min/hrs Pump Throttled? Yes 40
Dose Drawdown (in inches) 1 in.
Pump 2 - Man./Model Flow Rate qpm
Pump Location (i.e. garage, treatment unit, basement)
Float/transducer settings Inches Timer
from bottom of tank- On/off- in. Functions: On sec/min
Veto - in. Off- sec/min/hr
Alarm - in. Veto On - sec/min
Storage Above High Water Alarm gal. Veto Off- sec/min/hr
Dose Counter Reading # gallons/dose gal.
Elap. Time Meter Reading min/hrs Pump Throttled? Yes / No
If additional pumps- complete the info in this table
Dose Drawdown (in inches) in. for each and attach.
Other Timer functions & settings (e.g. override on/off)
H:\WEB\ONSITE\Asbuilt_Report_Form.doc 04/28/10page 1 of2
Pre-Treatment Date Insp
Sandfilter basin high water alarm shuts down pump to Sandfilter Yes / No
Sandfilter Basin size/location
Sand Fill met design spec? Yes / No
ATU (manufacturer, model) Alarm tested Yes / No
Disinfection Unit (manufacturer, type, model) Independent Alarm Yes / No
Drainfield
Transport Pipe size, schd, diameter 2" SCW-%'D Manifold size/schd 2.' &{40 ( $ t201''/
Orifice size Lateral Size/schd 1" ScE1 go 1°I sgt-70
Barrier Material �{ (C.vikeatc. Cover Material/Depth J1,ATI */1Z" 11.51Tari
Residual Head (lat.# & ft. Head) 12 SQQDtr tgf.f1' c1JJ,y 2215
The laterals/pods were balanced / No ci,.A like%11/5°
Source/Manufactur- of Drainrock/Gravelless chambers Corrom 1220%61■X
Drainrock Clean? No If no, what action taken?
Mound/Glendon Site Prep
Drainfield Length 3040 ft Width 3 ft Depth dZ inches
Caps for measuring residual head stored (location) 1 N litrret.ticoc
COMMENTS (inspection notes, changes from design or deficiencies in installation)Attach additional
sheet(s) if necessary
Health Department Inspection issues resolved Yes/ No / NA If yes how?
Users Manual Provided to Homeowner lb`/ Date
Tank/component Decommissioning Report Attached Yes / No NA//
Installer Certification attached/signed Yes/ No
ATTACH RECORD DRAWING stamped/signed by Designer or Licensed Professional Engineer
I CERTIFY THE INFORMATION PROVIDED ABOVE WAS VERIFIED 8Y INSPECTION, THE
•
SYSTEM WAS INSTALLED AS DESIGNED AND APPROVED by JEFFERSON COUNTY
7/t//IDATE) OR THAT CHANGES HAVE BEEN NOTED AND
AN E WI WAG 246-272.45,
Designer Signature D e License#
H:\WEB\ONSITE\Asbuilt_Report_Form.doc 04/28/10page 2 of 2
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Check one:
INSTALLATION START NOTIFICATION DATE SENT
XI PRESSURE/PUMP TEST INSPECTION REQUEST DATE SENT ryry
This form shall be faxed or emailed ONE working day prior to starting construction
OR a minimum of 48 hours prior to pressure/pump test
Jefferson County Public Health- Environmental Health Dept.
Phone: 380-385-9444 , L0
FAX: 360-379-4487
EMAIL: septic d�rcojefferson.wa.us MAY 2 6 Z015
PERMIT OWNER u 'yam 4 left r
SITE LOCATION It, 1 . 'e Tiou.in
PARCEL NUMBER Ci t ° t fl 2r 064 SEP NUMBER
INSTALLER tKeAp, CONTACT A
DATE FOR INSPECTION
SYSTEM WILL REQUIRE PRESSURE TEST - YES NO
*The designer is required to complete a pre-cover inspection of all systems. Please contact the designer
prior to beginning construction to schedule Installation Inspections and pre-construction meeting if
required per the permit or designs specifications.
Jefferson County Staff Only:: 4
MONITORING AGREEMENT MAILED DATE/INITIA 1 PRESSURE TEST SCHEDULED ,
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Nathan Cleaver Septic Design Inc.
Contractor Registration;: NATHACS94002
Soil Logs
Re: Renae Gunstone-White
Parcel #: 901 171001 Lot A
Soil Logging done on 8/I 1/2009 by Nathan Cleaver
Soil Log #1
0-2" Duff
2-36" Sandy Loam ra,1
36" Compact �l
CA(316;\
• �
A.2.-ivit.
'' L ht loulin beYinning at 26"J r
Major Roots to 36" ∎�
Soil Log #2
0-2" Duff vK_ 2 4.-.
2-22" Sandy Loam
22-36" Mottled Silt Loam �� '� �
Major Roots to 22"
Soil Log 43
0-2" Duff
2-36" Sandy/Silt Loar � � �� ��
Roots to 36" D� �,�,/�
Compact at 36" ��""
1"
Soil Log #4
0-2" Duff
2-36" /Silt Loam .- 3C0
`its to 36" s
6.,
Please feel free to call with any questions.
thank you.
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Licensed Unsite Wa,tevvatcr Treatment S4;tem Desi_ner. ; ,PE,S 7 �v '
OCT 1 201:
lticlres5: telephone: ;r)t' oNS i> ; lh
V'0O Kim1),111 Rd. .A\1 Fax: ;60- ')')8-63--1B
, ,J( )%), �,v-i 'U) i, U malt: Rattan`°'naina'n(._it,aA,er.( Orll
Please call ,tlled(�1 a) nl,tke dii ,lplwintnlent 11 \1)0 \,\mild like to Meet \\,it'll nle.