HomeMy WebLinkAboutSEP2013-00018 h0 to■
eii 0437.A.
Jefferson County Department of Community Development ,1- -.,.
621 Sheridan St., Port Townsend WA 98368,(360)379-4450 te�� - 2 Th.%
SEPTIC PERMIT APPLICATION ,'r..... ERIC 00CLEgVER 70,
PROPERTY OWNER 4 2,!L* A p"14-/ /G� .•.si.Nf.....����
MAILING ADDRESS f y� �v �j/ST 5`f-,
EXPIRES /_c/y
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PHONE ( Z96 j 3-6�9- 8-2.95 SYSTEM DESIGNER £R/C Designer Phone# �60 —4 ZE-2276'
LEGAL DESCRIPTION: Section Z9 Townshipc/✓Range 2 W PARCEL# s®z Z pia®Z-
Subdivision Name Q Division Block Lot(s) `/
Site address/Directions to site /1 P&. die CO✓e.,
SOURCE OF SEWAGE/USE TYPE OF WORK WATER SOURCE
Residential X New Tank/s only Private
Residential ADU Modification Public X
Commercial Expansion X
Community Upgrade
Repair SITE SIZE / `,'r
SYSTEM TYPE Partial Repair-(tank) (drainfield) Previous Evaluation
Conventional Designate Reserve Area Yes#
Alternative X Redesign - ---
No .
• SYSTEM DETAILS ,
Number of Gallons/day 36 O Soil type !7 (attach soil eval.) Application Rate . 4 gal./sq.ft./day
Drainfield Length 2d20 ft. Trench Width 3 ft. Trench/Bed Depth /6 in.
Septic Tank size 4/sc. gal. Pump Chamber size //OD gal.
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TYPE of system Pjre,,53't', 42._ CJ/J7%'/d 0/ fist
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1
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 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 its employees, representatives or agents for the sole
purpose of application review and any required later inspections. Staff's 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 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.
---Z - - — 3
Property Owner Signature r Date
FOR OFFICE USE ONLY P,,
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JEFFERSON COUNTY PUBLIC HEALTH
615 Sheridan Street • Port Townsend•Washington •98368
www.jeffersoncountypublichealth.org
' one •1- : _• ax •1- •_
ON-SITE SEWAGE DISPOSAL PERMIT
PERMIT #: SEP13-00018 Date Received: 02/13/13
SITE ADDRESS: 11 PARADISE COVE Date Issued: 02/25/14
BRINNON, WA 98320 Date Expires: 02/25/17
APPLICANT: LOREN R MATLICK PHONE:
PO BOX 51245
SEATTLE WA 98115
LEGAL DESCRIPTION: S29 T25 R2W LOT 4(E 100')TL TX F
• PARCEL#: 502293002 Section: 29 Township: 25N Range: 02 W
DESIGNER: ERIC CLEAVER PHONE: 360-620-2276
21257 FEATHER RIDGE LN. NE.
CLEAVER CONSTRUCTION
POULSBO WA 98370
SYSTEM DESCRIPTION: PRESSURIZED TRENCH
No. of Gallons per Day: 360 Type of work: NEW
Drainfield Trench Septic Tank
Length: 200 feet Width: 3 feet Depth: 15 inches Size: 1,150 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.
2
Jefferson County Environmental 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
CONDITIONS OF APPROVAL - PERMIT NO.: SEP13-00018
1.) H - THE EXISTING GREYWATER TANK THAT WAS RECENTLY ABANDONED MUST BE
CONFIRMED TO HAVE BEEN PROPERLY DECOMMISSIONED.. Documentation to be provided
to Health Dept. prior to final.
2.) H - All existing plumbing, including the recently abandoned greywater system must be plumbed into
this new system. MUST BE VERRIFIED AT FINAL INSPECTION.
3.) This system must be constructed by an installer certified by the Jefferson County Public Health
Department per state code WAC246-272A-0250.
4.) H - The existing water line must be re-located and maintain a 10' separation from any septic
component as per design.
5.) Divert all sources of drainage, including roof drains away from septic tank and drainfield area.
6.) Contact designer prior to installation for staking of drainfield area.
7.) 50' Setback to surface waters required from tanks.
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.) H - Existing tank shall be properly abandoned. It shall be pumped and filled with clean fill.
Documentation to be provided to Health Dept. prior to final.
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.) 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
13.) Health Dept. required to observe pressure test with system designer when system fully
installed/complete, 48 hours notice to be provided for scheduling.
14.) Notification of the start of construction shall be faxed or emailed to Jefferson County Public Health
ONE WORKING DAY prior to start.
15.) Drainlines are to be installed along the natural contours.
16.) Any portion of transport line under a driven way is to be sleeved/cased or equivalent.
17.) 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.
18.) 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.
19.) 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.
SEP13-00018 Page 2 of 3
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JEFFERSON COUNTY PUBLIC HEALTH, 615 SHERIDAN, PORT TOWNSEND WA 98368
ASBUILT INSPECTION REPORT For RECORD DRAWING
Designer �I- ra C/pie/ Permit # SEP /�3—Opp/p
Installer ./9 i k,. A h r..c A t 4 t o o l a.f o t A i s Parcel # 50022 ?3—iV
Electrician Design Flow 3k
Property Owner Lore,: /1/4.,i/ IC " ..,,
Site Address 1/ Ontei(ge Cove, gi-Aelm (4 •
Answer all questions or indicate NA G`ow
r,,,, -t
r C?/3, DATE
Tanks, Pumps and Controls -, INSP.� �
Tank (manufacturer, size, baffles) � erMw.. Pe -('__As/-- 1.5vo .9l `W.y,Zy
,1
Pump chamber (manufacturer, size) er,s pn Pre —eAsf 1lCb 94,1
Screen(s)and/or Pump Shroud (type, location) /(r,r'—Me Lte-.) FF-- y
Zed M. outside. &Mlle
Were Tanks tested onsite for water tightness? r= No
Timer Model .s,HG 4s `' "
Panel Model�/m.t6vs 1022`l39 /70,.3&/
Pump 1 — Man./Model liletty acre) Flow Rate 02.6_D qpm -, ),
Pump Location (i.e. garage, treatment unit, basement) /t/.v1,p 7k
Float/transducer settings Inches Timer
from bottom of tank- On/off - ,Z0 in. Functions:. On JrdZ sec/min
Veto - in. Off -.Z. sec/min/hr
Alarm - La in. Veto On - OA sec/min
Storage Above High Water Alarm ' 2D gal. Veto Off - VA sec/min/hr
Dose Counter Reading /l # gallons/dose 2.2.s gal.
Elap. Time Meter Reading /6 min/hrs Pump Throttled? Ye o
Dose Drawdown (in inches) I n 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 of 2
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 siz , schd, diameter ,J/,D V Manifold size/schd / SG,/D ei
Orifice size R ' Lateral Size/schd / " SCJ/D `/0
Barrier Material 67,'&Ve/%s5 Clb„ft r Cover Material/Depth gc*;vo Pir--45 ;ft
Residual Head (lat.# & ft. Head) 6-
The laterals/pods were balanced / No _
Source/Manufacturer of Drainrock/Gravelless chambers �i'ltml,,C Lor✓ fro
Drainrock Clean? Yes / No If no, what action taken?
Mound/Glendon Site Prep
Drainfield Length oZ/y ft Width 3 ft Depth /5 inches
Caps for measuring residual head stored (location) A'l , /o/d
COMMENTS (inspection notes, changes from design or deficiencies in installation) Attach additional
sheet(s) if/�necessary)/anks /44vc 4e , iask,//ed /n a. d,;4,,.,f- lode. 74"O. or 7,,t,/ ,a/kn.
>/g"6/`4-- Lerdr port .#f '1'9,ibaosor AA Ltw&s atbA.ec •al. -2-7c 44 s Sruo-Aed in I J/wv(ed 0t .5:.;e5
sr
. .. . . .. ` .. t ' oC.: , / ' ' ,, ..,
Aovsp Gvat C4rheishra(. AL el.cfays ,04..,6fy /`enu,"s
Health Department i pection issues resolved No / NA If yes how? 4 Scrcg., Liar lip„„
.
!✓lsya!!ed S,`,z,,e 0,45
Users Manual Provided to Homeowner L0,en i'&M k Date 7//4J
Tank/component Decommissioning Report Attaches No / NA
Installer Certification attached/signed
ATTACH RECORD DRAWING stamped/signed by Designer or Licensed Professional Engineer
I CERTIFY THE INFORMATION PROVIDED ABOVE WAS VERIFIED BY INSPECTION, THE
SYSTEM WAS INSTALLED AS DESIGNED AND APPROVED by JEFFERSON COUNTY
(DATE) O2 l-MT CHANGES RAVE BEEN NOTED AND
T , IN COMPLIANCE WITH WIC 246 -272.
5
Designer Signature Date License #
H:\WEB\ONSITE\Asbuilt_Report_Form.doc 04/28/10page 2 of 2
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CERTIFICATION OF TANK DECOMMISSIONING
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Parcel number SC7 el 00 2
Address ; i PCt ra . 5" C f,\p-<. `,+ :i!`;C.,?
Property Owner Name lvlc<t'-ic,V
Septic Permit# (if applicable) S,P I-3-0001?
Individual/Company Certifying Abandonment
G# f CL's i r t tc ;oY 131, k.c R(711/1/€5-t .w.0 tee' uv%1flat'a ci3
Phone Number /52(:)- gG6- 1Qg3
I certify that all sewage was removed from the septic tank and/or pump chamber
on the above referenced site by a Jefferson County Certified Septic Tank
Pumper, the lid was crushed and the tank filled with soil or gravel.
I certify that the septic tank and/or pump chamber on the above referenced site
has been decommissioned to Washington State and Jefferson County Public
Health Requirements.
Signature /;,--2/7-1 Date 9117jIS
Print Name lat.,(or Ica
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Pump receipt attached •
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Ca, / 1 2495 Cape Geo •e Road flin
7,--71-; �f`` �� Port Townsend, . A 98368
ii SEPTIC TANK OPERATIONAL AL REPORT 360-385-7155 • 360-457-4121
Date of Service,, 1 ? /; '/
Technicians signature " ,,
. ... _.9"-7,,,,
Service provided for
Address .4 F./1e
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P "6 t � ,.Phone � •=r,
Job Address 1 .! Pct/buP/SP EWe. t • nPtaMn
Last Date Pumped #people in home #bedrooms
SEPTIC TANK
Size of tank Gallons Compartments: Single Double
Material: Concrete , . Polyethylene Metal Other(specify)
Conditions of septic tank: Good Poor ; %"
Was ground water observed leaking into tank 2 Yes No •
If yes, where was water observed?
Effluent running back into tank from drainfield? Yes No t�'
Riser to grade on inlet:Yes—No-; 'Riser to grade on outlet:Yes_No_!'Riser to grade.on cieanout access:Y:s . No
• ' -' ,.---.
If no risers, were risers installed? Yes No '°
Solids in Tank: 1st compartment Scum (top layer) in. sludge(bottom layer) in.
2nd compartment scum(top layer) in. sludge (bottom layer) in.
BAFFLES ,
Condition of inlet baffle: Good Needs Repair Repaired Material
Condition of center baffle: Good Needs Repair . Repaired Material
Condition of outlet baffle: Good Needs Repair.. Repaired Material
Type of outlet baffle: Unscreened Screened i Filtered Material
Cleared outlet baffle and/or screen: Yes No 1 •'
PUMP CHAMBER I EFFLUENT PUMP
Does the system include a pump? Yes No If Yes, complete the following
Size of Tank Gallons
Riser to grade: Yes No If no;was riser installed:•Yes No
Material: Concrete Polyethylene Metal Other(specify)
Was ground water observed leaking into tank?Yes No
if yes, where was water observed?
Depth of accumulated sludge in pump tank inches
Was the effluent tank pumped? Yes _ No
Recommended additional information
Condi:ion of Pump: Working Not Working Needs repair
Condition of Alarm: Working Not Working Needs repair
Pump cycle drawdown: Inches Time for pump cycle minutes/sec.
Comments: '0/' ��r
• -
Good Man inc. 11, °
ilifIVOiCe
2495 Cape George RD.
P.m Townsend. WA 98368 Date Invoice 74
360-385-7155 128:2014 77059
en
4`\
Bill To
el"
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Petitjean Construction
Cordon Pctitjean
309870 Hwy 10:
(-
Brinnon WA W320
P.O.No. I Due Date
'
,2i<12014
!tern Description
Qty Rate Amount
Sc tie Service Cull riz_ I I Paradi:se Cove.Brinnon 1 113.30 113.30
Sc Itic Pumped 300;.zul.lor abandonment 3)))) 0.37 111.00
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Current Total $224.30
Ter us Are Net 30. 1.5%Finance Clutr;I!e Will Be Applied To All Past DuL.Balances
Sales Tax (9.0%) Scut)
Balance Due 5214.31)
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Li-ER 500< SEWAGE DISPOSAL DESIGN
RISERS TO SURFACE Approved fo p o ction
g Date
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INLET
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Pump Tank Cross-Section 1
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Pressure Distribution On-Site Sewage Disposal System Work Sheet
Name of Applicant: Loren Matlick Tax Assessors# 502293002
Designer's Name/Company Name: CLEAVER CONSTRUCTION INC.
Pressure Distribution:
Lateral, Manifold & Transport Information:
Lateral Pipe Length 200'
Total.......................................
Lateral Maximum Length 70'
Lateral Line Diameter 1" x,14
Lateral Spacing 5 O.C. `iqg`e ,,.
Lateral Line Pipe (Schedule-Class) Sch 40 A:
I,cs ERIC N.00122 ER
Manifold Line Pipe Type (Schedule-Class) - NA ''
(if applicable) EXPIRES&frt.A
Manifold Length - (if applicable) NA
Manifold Line Diameter— (if applicable) SCH 40
Transport Line Pipe Type (Schedule-Class) Sch40
Transport Line 80'
Length
Transport Line 11/2"
Diameter .
Pump In ormation:
Residual Lateral Head (Squirt 5'
Height) ......... ...... ...
Pump Capacity (GPM) 22.14
Total Dynamic Head (TDH) 37'
Dosing In ormation:
Orifice Spacing 48"
(inches) ......................................................
Total 54
Orifices
Orifice 1/8"
Diameter
JAN 31 2013
•
Total Dose Volume (gallons) 30
Number of Doses Per 12
Day...................................................•
Size of Pump Tank 1,100
(gallons) ................. ........ .........
Pump Capacity = (orifice discharge rate) x (number of laterals) x (number of orifices per
lateral)
(.41) X 54 = — 22.14 gpm
Total Dynamic Head (TDH) = elevation difference+residual head required+ friction losses
25+5+7 =37'
Other Information:
Avoid 90 degree bends in transport & lateral lines.
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FILENAME\p Macintosh HD:Users:robertstoner:Doccuments:Work:Forms_Design:Borrego_Pressure_Spec.doc
JAN 31 2013
Cleaver Construction Inc.
21257 Feather Ridge Lane,Poulsbo,Washington,98370 Phone 360-779-5652
Soils logs a I ecember 19,2012
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Loren Matlick �,.
146 NE 61st St. ���:�`�
Seattle, Wa. �Co.$ • ,v
98115 �� f w. ,.. ,�
206-369-8245 4. `-to
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EXPIRES/2I ,/y
Re: Tax # 502293002
Soil log # 1; 0 - 39" Brown Sandy Loam with Cobbles � �'_ l L
39" Water t i( .� 3'1 >
Roots to 39" m 11 �f `' __-_-__.....----
144 at' k
Soil log #2; 0 -42" Brown San oam Cobbles, C' 'j .3 I
42" Water t5 ' ywk & 41
c L5 fyyktpt
-act- .�h�lna . . -____-
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Soil log #3; 0 - 36"Brown Sandy Loam with Cobble cdt`t 3 "
36" Rocks ;r , 611 "'
Soil log #4 0 +> 39" Brown Sandy Loam with Cobbles
0 35 + 15C JAN 3 1 2013
,ii.5., pp., )