HomeMy WebLinkAboutSEP2015-00141 Jefferson County Department of C i mmunity Development
621 Sheridan St., Port Townsend WA 98368, (360)379-4450 c<• ,,,l' v 402,,,
SEPTIC PERMIT AP LIGATION
THOMAS MCNERNEY
PROPERTY OWNER 0, 0
64 OLD POIN I WHITNEY ROAD
MAILING ADDRESS
t3HINNUN, WA6HINU I UN 93?f 15#0
0/
PHONE '.428 "‘--484-86(44A0(' 510° g /1-/AS .;t. c .6' 4
( )
SYSTEM DESIGNER NATHAN N. CLEAVER Desig4r Phone# 360-598-6546
LEGAL DESCRIPTION: Section 18 Township 26N Range 1W 1 PARCEL# 601-181-010
Subdivision Name Division_______Block Lot(s)
64 OLD POINT WHITNEAD, BRINNON
Site address/Directions to site
SOURCE OF SEWAGE/USE TYPE OF WORK WATER SOURCE
Residential New Tank/s onl VP Private
Residential ADU Modification I Public
Commercial Expansion
Community Upgrade
Repair ,
SITE SIZE 831,124+/-
SYSTEM TYPE Partial Repair-(tank) (drainfield) Previoulttaticin
i-vb-UU42
Conventional Ibr Designate Reserve Area Yes#
Alternative Redesign No
SYSTEM DETAILS
120 EXT EXT
Number of Gallons/day Soil type (attach soil val.) Application Rate gal./sq.ft./day
70 (EX I) 3 30 (EXT) i
Drainfield Length ft. Trench Width ft. Trench/Bed Depth n.
1,000 NA
Septic Tank size gal. Pump Chamber size qal.
SEPTIC TANK ONLY DESIGN
TYPE of 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 materr fact made by the applicant/owner with respect to this
application packet may result in this permit being null and void. I furth r agree to save, indemnify and hold harmless Jefferson
County against all liabilities,judgments,court costs, reasonable attorney's fees fees and expenses which may in any way accrue against
Jefferson County as a result of or in consequence of the granting of this p it.
I further agree to provide access and right of entry to Jefferson County nd its employees, representatives or agents for the sole
purpose of application review and any required later inspections. Staff* access and right of entry will be assumed unless the
applicant informs the County in writing at the time of the application thathe or she requires prior notice. Inspections shall occur
during regular business hours. Initial here if you require notification befor entry
I
Appeal -.A person aggrieved of a decision of the Health Officer may ap eal. Appeals shall be submitted to the Health Division in
writing within fifteen days after receiving written notice of the decision.
I
DISCLAIMER-This application is for an on-site sewa0 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 ) 1/IT Ill c Elf) ASBUILT ; 2-/Z. 34rtit7FINAk;M 51 ccti1S-
! ?
APPROVE
INSP/PUMP TESTPUD l'1 "I( 5- T.._I" ip
. r
ALL HOLD REQ.MET•&AKIN1-e-rs I/'\ I 4. /aq//6- o2.-c- ,040
zz,
-7(:),/, i i n•
Date .1116) it)— Fee to, Rec* i I eti (-- I k•V Check* r --)--L-1 I Case*SEP L S -- 00141
H:\WEB\PDFs\SeptieVsepticpermitapp 2008.DOC 1
JEFFERSON COUNTY PUBLIC HEALTH
615 Sheridan St.
Port Townsend, WA 98368
dee www.jeffersoncountypublichealth.org
Public Health Phone 360-385-9444 Fax 360-379-4487
ON-SITE SEWAGE DISPOSAL PERMIT
PERMIT#: SEP15-00141 Date Received: 11/09/15
Date Issued: 12/17/15
SITE ADDRESS: 64 OLD POINT WHITNEY RD Date Expires: 03/17/16
BRINNON, WA 98320
APPLICANT: THOMAS C MC NERNEY PHONE:
17143 133RD AVE NE#186
WOODINVILLE WA 98072-8526
LEGAL DESCRIPTION: S18 T26 R1W TAX 7(LESS TAX 9)TL TAX H
PARCEL#: 601181010 Section: 18 Township: 26N Range: 1W
DESIGNER: NATHAN CLEAVER PHONE: 360-598-6546
NATHAN CLEAVER SEPTIC DESIGN
262 NW THOMPSON RD
POULSBO WA 98370
SYSTEM DESCRIPTION: SEPTIC TANK TO IND SYS
No. of Gallons per Day: Type of work: REP
Drainfield Trench Septic Tank
Length: feet Width: feet Depth: inches Size: 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 Envirro mental 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 REVERSE & ADDITIONAL PAGES
CONDITIONS OF APPROVAL - PERMIT NO.: SEP15-00141
1.) This permit was issued to correct a violation of WAC 246-272A for a leaking septic tank. The permit
must be completed within 90 days of the date of issuance.
2.) Approval/issuance of a sewage disposal permit or installation of a septic system does not
guarantee the approval of other development or a building permit on this site. Future buildings that
require connection to an on-site sewage system (OSS) shall only be approved if the OSS meets
the current standards and codes in effect at the time of the building application.
3.) H - Permanent barriers are required as per design, blocking access to primary drainfield areas to
protect from parking, driving, and other land disturbing activities prior to final.
4.) 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.
5.) 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.
6.) H - AS PER WAC 246-272A AND 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.) This system must be constructed by an installer certified by the Jefferson County Public Health
Department per Jefferson County Code 8.15.120 (9) and state code WAC246-272A-0250 due to
shoreline.
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.) A screen shall be provided at the outlet of the septic tank
13.) Distribution box/ lateral end, shall be fitted with a riser to grade, constructed of durable materials
and a secured lid.
14.) 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.
15.) 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.
SEP15-00141 Page 2 of 3
\\tidemark\data\forms\F_SEP_Permitmod.rpt 12/17/2015
16.) This approval is for a septic repair 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.
17.) The revised site plan as submitted with the septic repair application on December 09, 2015 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
approved site plan shall be resubmitted for review and approval by Jefferson County Department of
Community Development.
18.) This project was reviewed and approved as a Shoreline Exemption under JCC 18.25.560(2).
19.) This proposal is consistent with the Jefferson County Code Interpretation date August 29, 2014 for
repair and maintenance of legal nonconforming onsite sewage systems. The proposed repair to the
septic tank and drainfield is exempt from critical area review under JCC 18.22.070(6) and (21).
20.) The application was reviewed by the Jefferson County staff for the potential presence of Critical
Areas under the provisions of the Unified Development Code (UDC). After a Geographic
Information Systems mapping review the following Critical Areas were confirmed to be present on
the subject property: Marine Shoreline Fish and Wildlife Habitat Conservation Area, spotted owl
habitat, seismic hazard, intermediate and unstable shoreline slope stability, susceptible aquifer
recharge area, high risk seawater intrustion protection zone.
21.) Geologically Hazardous Areas in Jefferson County are characterized by slope, soil type, geologic
material, and groundwater that may combine to create problems with slope stability, erosion, and
water quality during and after construction or during natural events such as earthquakes or severe
rainstorms..
22.) A vegetative buffer of 30 feet shall be permanently maintained from the top or edge of the
Landslide Hazard Area. All buffers shall be measured perpendicularly from the top or toe of the
Landslide Hazard Area.
23.) Landslide Hazard Areas and their associated buffers shall remain naturally vegetated. Should
buffer disturbance occur during construction, the Unified Development Code (UDC) Administrator
shall require replanting with native vegetation. No alterations shall be made to the Landslide
Hazard Area or its associated buffer without prior authorization by the UDC Administrator.
24.) Prior to and during approved construction activities, the perimeter of the landslide hazard area
buffer shall be marked with a temporary sign. The sign shall be placed in such a manner that it can
be directly observed from the construction area. The sign shall contain the following statement:
"Landslide Hazard Area and Buffer- Do not Remove or Alter Existing Vegetation."
25.) All construction activities shall not encroach upon the 30 buffer. This includes the storage or
preparation of materials.
26.) The applicant shall permanently separate the boundary of the Landslide Hazard Area Buffer from
the remainder of the subject property through installing logs, trees, a hedge row, or any other
prominent physical marking approved by the UDC Administrator.
SEP15-00141 Page 3 of 3
\\tidemark\data\forms\F_S E P_Perm itm od.rpt 12/17/2015
CONVENTIONAL SYSTEM ASBUILT INSPECTION REPORT
INSTALLER M a+horN C.1-ec r PARCEL # 6()%/6)/c) /a
T
Permit Owner --,7-10,0t 7 (1 ,01/ lr�' it'lty Permit #` /5- - XV q/
ABSORPTION AREA:
DRAINFIELD TRENCH TRENCH TANK #OF #GAL/
LENGTH WIDTH DEPTH SIZE/ ` BEDRMS DAY
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 0 SE STEM WAS INSTALLED AS DESIGNED, PER PLAN APPROVED // / 6^
/G Z.//, Il
� A/TFff
INSTALLER SIGNATURE DATEINST LLED
'Ian oz/ 17, iti e_ //
eite„,i -- 7)#,-- f-'3-
ft, hge,,,, I P'\ 0117 ''
i C ire�-'C6 a
,4 (4„,
r0` , 0-tp 4
ASBUILT CONVENTIONAL.. FRM_05-10 04 poi"
,
I
i
I I
'di
D I I
/ I I p
d �
xmco? n n mO -
/pO = N` ,r`.
/4•_..c., * -+
CD
o
v
s,
CD
•
•
^ J
} 3
O
gj
•�
.. d
__„,,_
t:J
-,,,
0
....,
-.„.„,
5,„,„„.gi
,..„,
-..-...,
----_,..
ti
.....
,_,„,,
.,-,
N.
D:,..., -...,
H )-ii A
..
,,,
2r) wN
N.
d�
H
_may
Da
00
co
'xi b4
co 0
04 0
P.
x m /'
rn
t:i Lt
M
bJ
d j
O
ii
'1.
V \ \
1
I
;----Ir-. 'D
p CSA d L-4q T)
I til
m, i Era`ST,',� 0 l a)gi 1,4
M�� za �fi 5` � � 7 Zs �
0
00 r
S�. O cnx�'j voon - om mm,:41 Ir : a n -, n_llg,� •<. D
• r
CD C13 Li U)
r
'
CA
U)
0 0
O
(D CZi\ 7n♦ -. n)
� O-01 ✓ carp C oZ
n WH
ic)
PD
n 13g
tt
\-I x rooZ y Ny
0,.C0
p 0 . N z ,� � ,75 75
O aP
(mO � Z O w Q 0 `` DI
` HpZ z Z O xm O O O m o CO U1 NZ `o ms Q (70D .../ �o 30-Di ti
ria V
co
co
Cri
11.
u' pb ‘V . zN o oO 4 \�
&I/
% b, a
4 4;
S ; ; 615 Sheridan Street
iCiefiejsot
-/ out* Port Townsend, WA 98368
Public Health www•JeffersonCountyPublicHealth.org
CERTIFICATION OF TANK DECOMMISSIONING
Parcel number (dO/ I3 C/' f )
Address / Y eJ fi�h /key ,roe?d &irv,e'
Property Owner Name il'u.- fikith'e
Septic Permit # (if applicable) ;SPP oG%y/
Individual/Company Certifying Abandonment
0. irCk
Phone Number
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 Date ry/S-
Print
Name a Ii /U V-kr-
Pump receipt attached 1�v e>tfre
Gf d C h
Community Health Environmental Health
Developmental Disabilities Water Quality
360-385-9400 360-385-9444
360-385-9401 (f) Always working for a safer and healthier community (f)360-379-4487
H:\WEB\EH-WQ\SEPTIC\Applications-Forms\cert tank_abandon.doc
) ,
/
// i I
I 1.
\
r-
‘
I I m
'Fi '63 3
,,/ li m
1 z
1 1
21 ) c) 71 c-) m CO CO CD -,
.----p (7)"
a 31.
_0 -, 3'
= 0
v) 0 = 0
. „ o —1 2 (o A- co co co
/4P' 0 a)
, x- =
, ,
•,..\'.,.,\ ,s.
FI' o
-a
(D
/
.p
'.
..,
-_
---
---
_--
---
-
------_--,,,,,,,
o
----
-4k.'
t-,
b1
H
ta
. i
i.,
___---- ,
_------
___----- ---
ai ca
1-3 Eiri ,
W ,-61 0
a) ,_3 gi R
..—.L.,
......._ . 6-1
0.1...., ..Ark rlIN
eillt , I" -.2 a F-1
...... 0 CD
1 0 tj txj
...-i,
fr?:0 0
4 k
,--.
• 1 - -cf zo 6 0
GC)
CO Nts. 0 rn
4 a) ,-.3
..
10
% a -
• ,
.0".
0 o
...... ,...._.______
fi .
— __
-------- __ _______t_ I'____...1 1. .
.___
.4 ---- -.,
(..-- ---
•:-.r. ,-- 15 -M-1. 1-1 1
17, ci- C.• di
'' .... .
CD '
0 N 7 co -,..., \•••
.•
• ,2 .4...... .,....._..e.
r)t:I m
t-4
Q 73
so UP k c_ 0
-.A 0,fa• 0,-.
0> r_J, 4 '
,
--i co • f--3 4
CD M
• .4, 61 tO t.4 Q • c: t4 '-i
. (,
/
i
0 0 > Z
,.
0 C C C M
=
0 0
/ M •.‹
,-, r- Iv CO— 0 >a) Z
/
44
-1 (i)- M, tt CD • 0
41Ktik .,
/
..c. • ct,
ca cn <
0)0 a 0
1 S
\ ,
1 0) c • z
/ ,
A ,
° • Z
CO p3 0 rt 1.11 Z K 0 X)
0.1 K
-0 —
cr, z ,— co .., a) —I -- 2, -0
0 ›. 2:2 .i. 0 0 2 c.,„ • .,,, N\ \
_.
m
Q z o . F-') -o co 0
Z 1— --) , 2' co
CO
t4 0
> 0 C) CO '''' ''' ° . N\ \\ .. ,' ,,,, - 5.0tli i i.i. •Z tz'''" peg
r•J Z ,7 .13 ..... 2 7,„
05;0...w ,..ic0 ...r.m...),\... MI::f,
0 \ ,----
TO, Ul 41D N\ ..„.
.., ,-- H
\\ -,,--
C"") > __I 0 r.., D.- a.- 17 f .1' , N \\ I
m m LO * ..I.
—‹ C‘i - 71 •••• P E.- .0/i. • \ ,,,, ,
, . .t
R.0 ,,,......,•c..r c7) v)
< > c° 8 013 ?<0 n -0 ...
- f .11/.z's --,--. u 0
< co i a) g_ - R ,T,§ •-1 •• V
\ \ \N\ \
'
' w f-3
r\) RI /N) =1" 0.) to (4
0 1 Xi 0 z < Cr al ci),S,0).T. "4 '•I'i,"...,
m (1), 0 0.=61. ,„....z.
N 4),0',--is .... . , ,
0 _( 0 , 6,...
- \ .
q 0 ,.., 7 ( m-p. ,.\ - ,di ,
0 3 > co- • r7- ,,,• 0 0- ,, \
oq-k > =
ry > cc, , „,,, •,0, > No o ••• 0 \ on
o 0 co cz = Sz rl . •ik i' N ,..„
---,,
.,..., (..) •••• N. • 4 ..1414
'N \,_ c ry
vi o co 't0iiii XJ 0
I, ig \ d
r\ <
N M
co al
\NN 03 P
1
L ;: N
4 W N F-+
C-3-111)--------------------.._____________
zDt> >
C m - 0cn m
0 m �� o
qi- 0 77 i ,-... W.r*• (
E' G ••-•,• •• O 5
01 3 (D O z 520 .r O
0 v 0 rr D O rt
n 0 a(D n rt C r)
Q Cn d(p f1 - ,-,-
e-1-
..•
`y .r�. "!`• • Phi) 0 (01 rt O a
�.
_ Ol
;• ,... •!!•,•'..4...'.••:..-••:.-...:%. :,..,.,..•••:,-.:.-„--1,:.%;..•• ::,•;, ,:*„ X ..„ 3
(n CU M
0 m. O rt n
O
0 - rt lIl O of (D
. •.• V) yic. •."'. CO ...h 5 (1)
(.1)_
v) v ai
3 n
C ( �a rt (�D
D C cn
5
rn 01 rim 33 =
- c,
0 0,a rt
0•• 0. 0 3
Mil cri
(D 3 3
2/ o N3
0 m �,
n O
vi
Co
13 „,
con
.. ai ._, _,,
m o.
...,..,.......:,...... ... .....:...:..._.,,...;..,.......:‘..-f',...4:':' ..'.1"-'4%.•:.*'t•;;6 z .,...A:.•,1 -:,.---.:
-13 rni O
Cr) ion III
m
-11
o � 0
4,. m ......r--1 \
3 n __
111")
-I � r (M
)>___,
rn
to GIZill
0
. z z
(4N * O F•
u v O) u
i
(n > N !?i r
3 -0 -, m
= (0D - -1 n
m rD * + 0
D m � '* 1-• N
vfp 3 -I o 3
. 0 N rn
cn
a) 0 a3 rn
; !: 1 (D •
n
O C13,
O 0 : =
(=D (nD
m 5 . y X H n> 0 Z 0 a o,
�N�_I O r- CZ W AO m m z S r-r 7" (D CU z z * W = -D
MI
75
E12HC
:• -co = A v)CI
• 0- Ti •t
Z K v fa
•
Xr- p ONz Q C STc :o v @Z O p m 0o N v 0 , y;,.�,..cn * ZZwp m Zi era„' •.8.vC7 O
rt,
6, z) 0 z < O co CO -..Co
a,oP -.f,`.4,:t
`C
17,
N D 3 co �„� ! r �� / 3J tea)
_O p W l f }�� (D OU)
%.
I I r I/•
z, 6'
m m
r« i o x C. o
a m Q
z=
Cl) O QtX' CO m co-1
r N
Fi. o
v
CD
Q /
b
u
/ I
1
14
1
I
4
s$
i •
/
i i
7
) 1
1 I
i l
t i
I
k
I
,
C.-
0
0
m rn
o O
•
z
'\` o ODz
\ C Ccm
r- rvW
mZo
D
\' 7rnpCn
Il..4'I
cn0a O
•
� C z
OynF � m
n
TJ
o c ' rgc --q/7- ' 1'- , mOA v to ta CeN y n x ND o z 1),4• .z ... /./.,
9 ��m Z > O R73 . � *` ' _ WZ 0 Vi� 'r • co '<W p Zm IlZ Q �7a, F N'
on,? . i•
m €+ > -,.•.4r • 0m z n W m m - Qk � � ,f.\ -a O5 73
ov., o yi i � pz ,
K
(0
\ NZO O W SS) ; �o/�
Z / . Ca ,
v z (O ? O o m ) 0 .p N t � \7 . 47
Z
m m * o -om A i# 0 = H
\ < C co w 2 m e x \ 0. g ' ' Cn
\\ 1
o
N Do
CO H1 \ \ �. \\ O Hz��
2N4in 0 41 • \."
C� � � v OD
o�� � � m
Mc/�/�,; e_1 er e ,
.)
SEP 77 —OO a
903 E. Caroline(// OLYMPIC HEALTH DISTRICT Permit No, �flfQ-1
Port Angeles, Wash. SEWAGE DISPOSAL PERMIT APPLICATION
Submit in Duplicate Builder r4
Courthouse j
Port Townsend, Wash, Date 8 / 5 / i In
73
OWNER ,' ,. 0 A ,) (.-'� 441. IG ADDRES" 1is7iti,- , o , � qrrl
--C
DIRECTIONS FOR LOCATING SITE0...t.,` /'�", .t, , .,1 „:-TT-d4
APPLICATION IS HEREBY MADE TO: INSTALL NEW SYSTEM REPAIR EXISTING SYSTEM
iv
d / /lj X/,Z 'e, t.1 ,, ,
TYPE OF BUILDING NO. OF BEDROOMS BASEMENT SIIZE ` NS
LER
DRAINFIELD LENGTH 7>1 WIDTH .> 1 DEPTI-j 5---/' #LINES / SEPTIC TANK SIZER lecc:A6'CJ4I --,
DRAW A DETAILED PLOT PLAN BELOW. SEE INSTRUCTIONS. SOIL TYPE c
De
V '
- tel
T
CP
1 or \<, r-ep4cc d s/ -,,, __ /
4 Venelo.rW Is N I t
N ...,e.L�. cvo dam-- l aJ& f1 ,A
‘ ir.,
c......J&.i c 7:„...
G
Sv, I 10
i
1.,
ANY CHANGE IN BUILDING OR SEWAGE DISPOSAL PLANS, LOCATION OR SITE, INVALIDATES T IS
PERMIT UNLESS PRIOR APPROVAL OBTAINED FROM THE HEALTH DEPARTMENT. 0
(DE�CSTALLATION SIGNATURE OF AP ✓lL a , -
APpRO .�`' DATE /5 7(c INSPECTED BY' s„, C3"�\'c._
t
SANITARIAN'S COMMENTS:
0
O
I CERTIFY E h si; .S WAS INSTALLEp—IN THE MANNER APPROVED BY THE HEALTH
DEPARTMENT . , f ,-°:. DATE
INSTALLERS NAME
OHD 6-75