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HomeMy WebLinkAboutSEP2013-00017 Jefferson County Department of Community Development 621 Sheridan St., Port Townsend WA 98368, (360)379-4450 c- -r-) (' ; „-., SEPTIC PERMIT APPLICATION PROPERTY OWNER AM5i///7/--aivPA1/-. �'` ,r< �= c.- •• MAILING ADDRESS /!/l �-�-4r-,P,,/ /2.J ,� ..'lj 04 k44,7,, Lt-/r1 9b5 ey • PHONE (Of_: [) ) 7-91--' .c/— cf e // 9 7 9OZ 'Gh O GS SYSTEM DESIGNER ('SCT ,,..,C; Designer Phone# 5- 6 96 -- ij LEGAL DESCRIPTION: Section Township Range PARCEL# (°32,1 ci 4./D/ a Subdivision Name in i ,1-,--.r /3i, 7 .�� ,/-7 3,^4 (S vision Block Lot(s) Site address/Directions to site • SOURCE OF SEWAGE/USE TYPE OF WORK WATER SOURCE Residential New Tank/s only )<— Private )C.//,1� Residential ADU Modification Public Commercial Expansion Community Upgrade Repair SITE SIZE SYSTEM TYPE Partial epair- (tank) (drainfield) Previous Evaluation Conventional Designate Reserve Area Yes# Alternative Redesign No i SYSTEM DETAILS Number of Gallons/day Soil type (attach soil eval.) Application Rate gal./sq.ft./day Drainfield Length ft. Trench Width ft. Trench/Bed Depth in. Septic Tank size gal. Pump Chamber size gal. TYPE of system /i- '7, /e- � ,i' _l i(y /�itr. iBy signing the application form, the applicant/owner attests that the information provide7)/Q rein 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. 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 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 futu e application will be separately judged by the rules and laws in effect at that time. ,.,..,, / —5--- 13 Property Owner Signature Date /,// l FOR OFFICE USE ONLY 11 1 C V/S PARTIAL �! ���I ASBUILT r ti� FIN �'/�!/ APPROVED INSP/PUMP TEST PUD / J ` ALLHOLD RE Q.eM#T • c. ,+ heck j� f Case#SEP / Dak�'` I Fee47 H:\WEB\PDFs\Septic\septic_permitapp_2008.DOC JEFFERSON Y PUBLIC HEALTH 615 Sheridan Street •Port Townsend*Washington .98368 www.jefferson countyp ub lichealth.o rg Phone.....360-385-9444' -Fax 360-37944'87 ............................_.............._............._............ ON-SITE SEWAGE DISPOSAL PERMIT PERMIT #: SEP13-00017 Date Received: 02/13/13 SITE ADDRESS: 10541 FLAGLER RD Date Issued: 03/14/13 NORDLAND, WA 98358 Date Expires: 06/14/13 APPLICANT: STATE OF WASHINGTON PARKS PHONE: AND RECREATION COMMISSION P 0 BOX 42650 OLYMPIA WA 985042650 LEGAL DESCRIPTION: S29 T30 RIE TAX#2&TL TAX#F PARCEL#: 021294012 Section: 29 Township: 30N Range: 01 E DESIGNER: CXT PRECAST PRODUCTS DIVISION PHONE: 800-696-5766 SPOKANE INDUSTRIAL PARK 3808 N SULLIVAN RD BLD#7 SPOKANE WA 99216 SYSTEM DESCRIPTION: VAULT/HLD TNK No. of Gallons per Day: Type of work: REP Drainfield Trench Septic Tank Length: feet Width: feet Depth: inches Size: 2,000 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. or/pk,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.: SEP13-00017 1.) H -An asbuilt drawing and certification of completion by the Designer is required prior to final approval. 2.) This permit was issued to repair an old vault toilet. The permit must be completed within 90 days of the date of issuance. 3.) 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. 4.) Notification of the start of construction shall be faxed (360 385 9401) or emailed to Jefferson County Public Health ONE WORKING DAY prior to start. 5.) The pumpout access must be secured 6.) Risers to grade with secured lids shall be located over all compartments. Access ports intended for use as pump-out sites shall be fitted with an impervious pad that slopes towards the access. All pumping and related service must be performed by a Jefferson County licensed septic system pumper. Permit Holder shall maintain and keep operational records which include pumping intervals, sewage volume, disposal site, service and repair records. These records shall be available upon request of the Health officer representative. 7.) 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. 8.) 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. 9.) This system must be constructed by an installer certified by the Jefferson County Public Health Department per state code WAC246-272A-0250. 10.) 10' separation required between any Water line and all portions of the vault toilet. 11.) Divert all sources of drainage away from vault area 12.) 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. 13.) This onsite sewage system is designed for domestic strength wastewater only. Disposal of any other waste strength is considered a violation of this permit. 14.) 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. SEP13-00017 Page 2''of'2 \\tidemark\data\forms\F_SEP_Permitmod.rpt 3/14/2013 •••• _ 1 ...< . cp, . ,..... i Al°RI:4 a "•-‹ al (7/ /kl. 4-1 , .... n ( ...., , .- -11. x ...1 TAiii..... ....-_, ......1 : -........ -• ..-j c), . 1141114 . ..e _ °4fOp / /4 44, 1 /50,4: 4°42-s. o eet _ 4 , , ... / "2 -c) . • 0 .. 1 / / 2 0 11111 co > K ' ::• ---.........__ / m > X -ir- -Z- c,L'• _ ... i / t a, m _ . • • _ TO FLAGLER ROAD -., /7 -..—.... ..--- --------• ...---... —.......--.• ,-................. ................ 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