HomeMy WebLinkAboutSEP2016-00160 Jefferson County Department of Community Development
621 Sheridan St., Port Townsend WA 98368, (360)379-4450
SEPTIC PERMIT APPLICATION
PROPERTY OWNER Brian Belt
MAILING ADDRESS 2570 E.Quilcene Rd.
Quilcene,WA 98376
PHONE (360)765-3990
SYSTEM DESIGNER: Michael S.Deeney Designer Phone#: ( 800 ) 395-7296 �'`)°21 <'` l6'
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LEGAL DESCRIPTION: Section 30 Township 27 Range 1W PARCEL# 701301016 Cfiv
Subdivision Name Division Block Lot(s)
`.t>
Site address/Directionsto site 2570 E. Quilcene Rd.,Quilcene
SOURCE OF SEWAGE/USE TYPE OF WORK WATER SOURCE
Residential X New Tanks(s)only Private X
Residential ADU Modification Public
Commercial Expansion
Community
Repair X SITE SIZE 18,002 sq. ft
SYSTEM TYPE Partial Repair-(tank) (drainfield) Previous Evaluation
Conventional X Designate Reserve Area Yes#
Alternative Redesign
SYSTEM DETAILS
Number of Gallons/day 360 Soil type 4 (attach soil eval.) Application Rate 0.6 qal./sq.ft./day
Trench Length 120 ft. Trench Width 3.0 ft. Trench Depth 28-36 in.
Septic Tank size 1,000 gal. Pump Chamber size N/A gal.
TYPE OF SYSTEM Reduced Size Conventional Gravity Graveless Chamber Drainfield
.ice.
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
Countyagainstall liabilities,judgments,courtcosts,reasonable attorney's fees and expenses which mayin anywayaccrue against
Jefferson County as a result of or in consequence of the granting of this permit. I further agree to provide access and rightof entry
to Jefferson Countyand its employees,representatives or agents for the sole purpose of application review and any required later
inspections. Staffs access and right of entrywill 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.
' t Jam" (0 —
Property Owner Signature Date
FOR OFFICE USE ONLY
C PARTIAL ASBUILT / /7 FINAL 6/I/
APPROV
INSP/PUMP TEST Monitoring Agreement \1\AOk` iI'v
ALL HOLD REQ.MET
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JEFFERSON COUNTY PUBLIC HEALTH
615 Sheridan,
Vate;,, Port Townsend, WA 98368
(�u, � www.jeffersoncountypublichealth.org
Public Health Phone 360-385-9444 Fax 360-379-4487
ON-SITE SEWAGE DISPOSAL PERMIT
PERMIT #: SEP16-00160 Date Received: 09/26/16
Date Issued: 12/11/16
SITE ADDRESS: 2570 EAST QUILCENE RD Date Expires: 03/11/17
QUILCENE, WA 98376
APPLICANT: MARJORIE D BELT PHONE:
BRIAN S BELT
2570 E QUILCENE RD
QUILCENE WA 98376-8529
LEGAL DESCRIPTION: S30 T27 R1W TAX 26
PARCEL#: 701301016 Section: 30 Township: 27N Range: 1W
DESIGNER: MIKE DEENEY PHONE: 360-379-2879
CREATIVE DESIGN SOLUTIONS
PO BOX 2787
PORT ANGELES WA 98362
SYSTEM DESCRIPTION: CONVENTIONAL TRENCH/REDUCED
No. of Gallons per Day: 360 Type of work: REP
Drainfield Trench Septic Tank
Length: 120 feet Width: 3 feet Depth: 28 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.
./7/7/ /''
Jefferson County Environm ntal 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.: SEP16-00160
1.) This permit was issued to correct a violation of WAC 246-272A for a undersized metal tank w/a
non water tight top and root intrusion. The permit must be completed within 90 days of the date of
issuance.
2.) This system has been designed using gravelless chambers and a reduced size drainfield.
Gravelless Chambers must be used.
3.) This septic system has been designed taking sizing reductions of the drainfield area. This permit
has been issued based on the understanding that the applicant has signed an affidavit that they are
making an informed decision and are aware of the increased risks.
4.) 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.
5.) 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
6.) 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.
7.) Notification of the start of construction shall be faxed or emailed to Jefferson County Public Health
ONE WORKING DAY prior to start.
8.) H - An asbuilt drawing and certification of completion by the Designer is required prior to final
approval.
9.) 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.
10.) Divert all sources of drainage, including roof drains away from septic tank and drainfield area.
11.) 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.
12.) Distribution boxes shall be fitted with a riser to grade, constructed of durable materials and a
secured lid, adequately sized to allow visible inspection of the liquid level in the box.
13.) 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.
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.
15.) 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.
SEP16-00160 Page 2 of 2
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JEFFERSON COUNTY PUBLIC HEALTH, 615 SHERIDAN, PORT TOWNSEND WA 98368
CONSTRUCTION INSPECTION REPORT
For RECORD DRAWING
Designer MICHAEL DEENEY Permit# SEP 16-00160
Installer EVAN NEVILLE WITH SHOLD EXCAVATING Parcel # 701301016
Electrician 1D9sign Flow 360
Property Owner BRIAN & MARJORIE BELT
Site Address 2570 E. QUILCENE RD., QUILCENE, WA 98376
Answer all questions or indicate NA
Tanks, Pumps and Controls Date Insp.
Tank (manufacturer, size, baffles) 1,000 GAL. 2 COMP. TANK W/BAFF & OUTLET FILTER 3/13/17
Pump chamber (manufacturer, size)
Screen(s)and/or Pump Shroud (type, location)
Were Tanks tested onsite for water tightness? Yes / No
Panel Model Timer Model
Pump 1 — Man./Model Flow Rate gpm
Pump Location (i.e. garage, treatment unit, basement)
Bottom of transducer to bottom of tank
Float settings (above bottom of tank) / transducer settings Timer Functions:
(above bottom of transducer)
On/off - On -
Veto - Off -
Alarm - Veto On -
Storage Above High Water Alarm gal. Veto Off -
Dose Counter Reading Gallons/Dose
Elap. Time Meter Reading Pump Throttled? Yes / No
Dose Drawdown (in inches)
Pump 2 — Man./Model Flow Rate gpm
Pump Location (i.e. garage, treatment unit, basement)
Bottom of transducer to bottom of tank
Float settings (above bottom of tank) / transducer settings Timer Functions:
(above bottom of transducer)
On/off - On -
Veto - Off -
Alarm - Veto On -
Storage Above High Water Alarm gal. Veto Off -
Dose Counter Reading: Gallons/Dose:
Elap. Time Meter Reading: Pump Throttled? Yes / No
Dose Drawdown: If additional pumps complete this info for each
\\LENOVO2D16DEC\Data\Wpw1County&State Forms\Jefferson\Construction Rpts\Conventional\Belt,701301016,Alternative sys ASBUILT 2010-2.FRM.wpd 03/22/17
Page 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 Size/Sch. 4" PVC Manifold Size/Sch. 3/9/17
Orifice Diameter Lateral Size/Sch.
Barrier Material GRAVELLESS CHAMBERS Cover Material/Depth 6" to 24" of SL 3/9/17
Residual Head (lat.# & ft. Head)
Source/Manufacturer of Drainrock/Gravelless chambers
Drainrock Clean? Yes / No If no, what action taken?
Mound/Glendon Site Prep.
Drainfield Length 120 ft Width 3 ft Depth 18 to 36 inches
Caps for measuring residual head stored (location)
COMMENTS (inspection notes, changes from design or deficiencies in installation) Attach additional sheet(s) if
necessary
Other Aquaworx panel settings: Swarn: , Zbios: , Autoclear: doses min-sec.
Health Department Inspection issues resolved Yes / No / NA If yes how?
Users Manual Provided to Homeowner WITH RECORD DRAWINGS 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 by inspection (with exceptions as noted, if any). I also certify that this on-site
system was installed in accordance with the approved design and verified through periodic observations of construction such as
site plowing for mounds, pressure testing with all system components exposed (no backfill, except over transport pipes), and final
inspection of the completed system (with exceptions as noted, if any). To the extent revealed by these periodic inspections, the
system complies with all the conditions noted in the permit as approved by Jefferson County 12/11/16 (Permit
Approval Date) or that changes have been noted and the system is in compliance with WAC 246-272.
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