HomeMy WebLinkAboutSEP2016-00065 Jefferson County Public Health �
615 Sheridan St., Port Townsend WA 98368, (360) 385-9444 444 ,!+t
SEPTIC PERMIT APPLICATION w,„ yti�
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Mary Ann&Korth Luedke
PROPERTY OWNER y
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MAILING ADDRESS 16038 3rd Avenue South#D uzapOeLMartin
••t:rcr6/6 tJtw'" Mfr,
EXPIRES 1
Burien,WA 98148
PHONE ( 206 ) 849-5495 p
SYSTEM DESIGNER Suzanne Martin Designer Phone# (360)990-3304 9�4
LEGAL DESCRIPTION: Section 23 Township 28N Range 1E PARCEL#983 400 112&983 400 14. Or
2� 4 ,
Subdivision Name Paradise Bay Estates Division Block 1 Lot(s) 12��,1i>
100 East Cedar,Port Ludlow,WA c} ��
Site address/Directions to site /�/ix,
e
SOURCE OF SEWAGE/USE TYPE OF WORK
WATER SOURCE
Residential ✓ New Tank/s.qnly Private
Residential ADU Modification ✓ Public ✓
Commercial Expansion
Community Repair •
Partial Repair-(tank) (drainfield) SITE SIZE 12966
SYSTEM TYPE Designate Reserve Area Previous Evaluation
Conventional Redesign Yes#SEP95-00262
Alternative ✓ No
SYSTEM DETAILS
Number of Gallons/day 240 ex. Soil type- (attach soil eval.) Application Rate ex qal./sq.ft./day
Drainfield Lengthr41913r ft. Trench Width 3 cx' ft. Trench/Bed Depth ex in.
Septic Tank size-344?-ex- gal. Pump Chamber size 500 ex gal.
TYPE OF SYSTEM new sewer line from proposed shop to existing pressure trench system(SEP95-00262)
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.
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roperty Owner Signature Date
FOR OFFICE USE ONLY }} In�
t& PARTIAL ASBUILT : / t�i 7 'FINAL f �• ,
AP'R. D
INSP/PUMP TEST Monitoring Agreement 41'4(( C-75/111
ALL HOLD REQ. MET 5741-3
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Date f ZR (d Fee �� Rec# ( /moi-3 Check# j(L) 5 h Case#SEP I —0 (
G:\B-ONSITE\Forms\Application Form & Info\2015 Septic Permit Application.doc
JEFFERSON COUNTY PUBLIC HEALTH
615 Sheridan ;
Port Townsend, WA 98368
www.jeffersoncountypublichealth.org
Public Health Phone 360-385-9444 Fax 360-379-4487
ON-SITE SEWAGE DISPOSAL PERMIT
PERMIT #: SEP16-00065 Date Received: 04/28/16
Date Issued: 06/17/16
SITE ADDRESS: 100 E CEDAR ST Date Expires: 06/17/19
PORT LUDLOW, WA 98365
APPLICANT: MARY&KOR LUEDKE PHONE:
16038 3RD PL S#D
BURIEN WA 98148-1490
LEGAL DESCRIPTION: PARADISE BAY ESTATES BLK 1 LOT 13
PARCEL#: 983400113 Section: 23 Township: 28N Range: 1E
DESIGNER: SUZANNE L MARTIN PHONE: 360-554-0224
PO BOX 125
CHIMACUM WA 98325
SYSTEM DESCRIPTION: TRANSPORT LINE
No. of Gallons per Day: 240 Type of work: MOD
Drainfield Trench Septic Tank
Length: 0 feet Width: feet Depth: inches Size: 0 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 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 REVERSE & ADDITIONAL PAGES
CONDITIONS OF APPROVAL- PERMIT NO.: SEP16-00065
1.) 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.
2.) 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.
3.) 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
4.) 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.
5.) Notification of the start of construction shall be faxed or emailed to Jefferson County Public Health
ONE WORKING DAY prior to start.
6.) H - An asbuilt drawing and certification of completion by the Designer is required prior to final
approval.
7.) 10' separation required between a Water line and all portions of the onsite sewage system; effluent
transport line, tanks, treatment and disposal components.
8.) H - This permit is granted based on the recorded RESTRICTIVE COVENANT combining lots for a
off site transport line. COVENANT recorded 598934
9.) 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.
10.) This onsite sewage system is designed for domestic strength wastewater only. Disposal of any
other waste strength is considered a violation of this permit.
11.) 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.
SEP16-00065 Page 2 of 2
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INSTALLER 1-1 vy1 - (JV' \ PARCEL #c9 3 'floc) H Z JO
Permit Owner Permit # P i ( fir- L05--
ABSORPTION AREA: „e1511 V p
DRAINFIELD TRENCH TRENCH = TANKS #OF #GAL/
LENGTH WIDTH ,(y DEPTH SIZE I OCC) BEDRMS DAY
Tank Shroud/
IF PUMP AND PUMP CHAMBER REQUIRED: Size Screen
Float Arrangement -1C--‘c) At,
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 THElp ONSITE SEWAGE SYSTEM WAS INSTALLED AS DESIGNED, PER PLAN APPROVED
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Page 1 of 4;Cybul;
Parcel#952 800 209
JEFFERSON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT
621 SHERIDAN ST., PORT TOWNSEND ,WA 98368, (360) 379-4450 1,
,, �f,
SOIL EVALUATION . �Ff►
PROPERTY OWNER Matt Cybul .�. ' S 0 2 Pf,,
Suzanne L Martin . f+
Suzanne Martin CfC@NSl D7Sr$i�NeA"' ff
SYSTEM DESIGNER E72/
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LEGAL DESCRIPTION: Section 2 Township 29N Range 1W Parcel # 952 800 209
Subdivision Name tax 170;v 404pg 449 Division Block Lot(s) Parcel A
Date Logged: 6 June 2013 Logged By: Suzanne Martin
Include soil textural characteristics and the depths at `hi h sig ' scant changes occur. Be sure to include depth
where mottling or impermeable layers occur. p �.
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SOIL LOG #1 _,_-\\. SOIL LOG #2
0 to 5 in. Dark brown loamy medium sand 5 in.Dark brown loamy sand
5 to 25 in.dark yellow brown gravelly medium sand 5 to 70 in. yellow brown medium sand
25 to 55 in.Yellow brown medium sand __to in.
55 to 69 in.grey gravelly medium-coarse to in.
Anticipated water table n/a in. Anticipated water table nia in.
Roots to 60 inches JUL 1 201 Roots to 55 inches
Health Dept. Comments Health Dept. Comments
Wte..---"'..
SOIL LOG #3 SOIL LOG #4
0 to 7 in. Dark brown loamy medium sand 0 to 12 in. Dark brown loamy sand
7 to 66+ in. yellow brown gravelly medium sand 12" to 42 in, yellow brown gravelly fine sand
to in. 42 to 50 in. yellow brown gravelly medium sand
to in. 50 to 64in yellow brown gravelly fine sand
Anticipated water table nia in. Anticipated water table n/a in.
Roots to 56 inches Roots to 64" is inches
Health Dept. Comme Health Dept. C ?101,t
(�m�e�:
SOIL LOG #5 SOIL LOG #6
to in. to in.
to in. to in.
to in. to in.
to in. to in.
Anticipated water table in. Anticipated water table in.
Roots to inches Roots to inches
Health Dept. Comments Health Dept. Comments
H:UNFOHLTHISOILFRM 1/00