HomeMy WebLinkAboutSEP1994-00079 S E P 94-00079
SYSTEM DECOMMISSIONED
NO LONGER VALID
r JEFFERSON COUNTY PUBLIC HEALTH
', 615 Sheridan Street • Port Townsend •Washington •98368
www.jeffersoncountypublichealth.org
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CERTIFICATION OF TANK ABANDONMENT 2�
Parcel number 70 /0 flq00 /
Address ""I 1 S o ® c-. 4.,i Po Si 0r-b4 /249,4
Property Owner Name No-4 411 W C9 ` jev -9 -s+
Septic Permit# (if applicable) /w/y4
Individual/Companny Certifying Abandonment
Re,-e-2 65-c4 L5-c4 Y1 (i' 1 are4
Phone Number 360 7 5 36 3 3 �J
I certify that the septic tank and/or pump chamber on the above referenced site
has been abandoned to Washington State and Jefferson County Public Health
Requirements.
Signature 1 ` Date J O ` 6 — j
Print Name \-)c) (..,)N. f
Pump receipt attached y>43 C on1 9 - 2 - /
COMMUNITY HEALTH ENVIRONMENTAL HEALTH
PUBLIC HEALTH
DEVELOPMENTAL DISABILITIES WATER QUALITY
MAIN:360385-9400 ALLAYS WORKING FOR A SAFER AND MAIN:364385-9444
FAX:364385-9401 HEALTHIER COMMUNITY FAX:364385-9401
. ..,,,,,,,„
6
2495 Cape George Road
Port Townsend,WA 98368
SEPTIC TANK OPERATIONAL REPORT 360-385-7155 . 360-457-4121
a Date of Service . ' -`/
r
Technicians signature , 7-, , (_ r
Service provided for /' ,'` .. ,�-�` t-'' _ ( �
Address ,-,
Phone 2.. .:�.) f-_. .. =`
ti
Job Address
- ,J ,a
Last Date Pumped #people in home #bedrooms 1
SEPTIC TANK
Size of tank /1 ,1 0 Gallons Compartments: Single 1 Double
Material: Concrete t Polyethylene Metal Other(specify)
Conditions of septic tank: Good Poor
Was ground water observed leaking into tank?Yes I / No
If yes,where was water observed? "
Effluent running back into tank from drainfield? yes No
Riser to grade on inlet:Yes_No/iser to grade on outlet:Yes—No ser to grade on cleanout access:Yes—No V
If no risers,were risers installed? Yes No is
Solids in Tank: 1st compartment Scum(top layer) (% in sludge(bottom layer) ,. i, . R
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 Rep Repaired Material,
Type of outlet baffle: Unscreened Screened z Filtered Material,
Cleaned outlet baffle and/or screen: Yes No V
PUMP CHAMBER / EFFLUENT PUM
Does the system include a pump? Yes No If Yes,complete the following
Size of Tank! 0( Gallons
Riser to grade: Yes VNo If no,was riser installed: Yes No
Material: Concrete V Polyethylene 'Metal Other(specify)
Was ground water observed leaking into tank?Yes No V
If yes,where was water observed? ,
Depth of accumulated sludge in pump t `, k inches
Was the effluent tank pumped? Yes V No
Recommended additional information
Condition of Pump: Working Not Working Needs repair
Condition of Alarm: Working Not Working Needs repair
Pump cycle drawdown: Inches Time for pump cle minutes/sec.
Comments: -) / it ,t °" : •
�, ` ':) 7- " ,, d ?
• • `�
JEFFERSON COUNTY PERMIT CENTER ,,V,1 FOR OFFICE USE
621 SHERIDAN 1 RECEIPT # l�C
PORT TOWNSEND WA 98368 / AMT. PD N A
1206) 379-4450 DATE -� —erkt
SEPTIC PERMIT APPLICATION
1 -10\ O 3 OOS
W
LEGAL DESCRIPTION: Section Township fl N Range I PARCEL # -10 1 a'r 00 \
Subdivision Name Division Block Lot
OWNER NAME R1 or.c e \ Rai, r S
MAILING ADDRESS /3Q/ 3 (Liec J
67rt 61'
PHONE LI-a - `l 3 (Q
SITE ADDRESS/DIRECTIONS 1\ cr)c,300b -P.0 . Rd . l A f gyp_ Q
c e ex- Rd -t n Co<. lse 2A to J)I Jh Q.c (RA (ATTACH MAP)
TYPE OF STRUCTURE eD\r\c. ,4) ��, ,Q (Zp ,
TYPE OF WORK
NEW UPGRADE REDESIGN
IC REPAIR
PARTIAL (tank or drainfield) k COMPLETE
Number of Bedrooms ,S Basement yes Nk no
Site Size I .3\ acres
Previous evaluation Y es no V 0 1
Water Source k private public
drilled well dug well other
ATTACH SOILS INFORMATION /0
/ C�C
TYPE OF SYSTEM 1 of \\r1 A 3c - \ `T(I\-� r� U,),)
1
Drainfield Length 3� Drainfield Width 1 0 OVITi
Trench/Bed Depth op/ Number of Lines 3 1c,Ae rc�\3 Ite
Tank size _k■S \r,cl gallons
Soil type (9 Application Rate I.0 gal/sq.ft/day
•
THE UNDERSIGNED ACKNOWLEDGES THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT AND THAT
FLASE INFORMATION WILL NEGATE AND INVALIDATES THE APPLICATION AND/OR THE SUBSEQUENT PERMIT.
THE PROPERTY OWNER WILL BE RESPONSIBLE FOR THE ACCURATE LOCATION OF ALL PROPERTY LINES.
Signature Date
OFFICE USE ONLY
- /1 i-15/
APPROVED PARTIAL FINAL
RENEWED RENEWED
h:HOME\PLNCNTR\IM OHLTH\PERMIT.FRM
4 .
SEWAGE DISPOSAL PERMIT
JEFFERSON COUNTY PERMIT CENTER
621 SHERIDAN STREET, PORT TOWNSEND, WA 98368 (206) 379-4450
PERMIT NUMBER:SEP94-0079
ISSUE DATE:03/15/94
DATE RECEIVED:03/03/94
Permit issued to CONSTRUCT, ALTER, REPAIR OR MODIFY AN INDIVIDUAL SEWAGE
DISPOSAL SYSTEM IN JEFFERSON COUNTY, WASHINGTON
ISSUED TO • RICHARD RAWLINGS
STR: 04-27-01W
PARCEL NUMBER • 701043005
(Permit valid for this/these parcel(s) ONLY)
LEGAL DESCRIPTION/SUBDIVISION: BL CK:
LOT(S) :
LOCATION • 1150 DABOB POST OFFICE RD
DESIGNER • JEFFERSON COUNTY WATER QUALITY `
THIS PERMIT IS ISSUED FOR A PERIOD OF ONE YEAR (UNLESS OTHERWISE STATED
DELOW) IN ACCORDANCE WITH JEFFERSON COUNTY RULES AND REGULATIONS FOR ON-
SITE SEWAGE DISPOSAL SYSTEMS, ORDINANCE NO. 1-83 . 6)1
DATE OF EXPIRATION:03/15/95 t f 79-/A-- . �(j Q�/',
Jef rson Co. Environmental Health Specialis.' i
t. )
The property owner will be responsible for the accurate location of all
property lines . Any removal of or major disturbance of soil in the primary
ur reserve drainfield area may create site conditions that are unacceptable
for the installation of a sewage disposal system. Any change in building or
sewage disposal plans (including plumbing stubout location) and/or location
of house or drainfield invalidates this permit unless prior approval is
obtained from the Jefferson Co. Health Dept.
Issuance of a permit or renewal does not preclude the applicant from
complying with all other state and local land use, planning and building
regulations .
HEALTH DEPARTMENT MUST BE CALLED FOR FINAL INSPECTION.
TYPE OF SYSTEM: UNLINED SANDFILTER NO. OF BEDROOMS: 3
-----Drainfield Trench Tank
Length: 36 ft. Width: 10 . 0 ft. Depth:24 in. Size: 0 gal .
SPECIAL CONDITIONS MAY APPLY - SEE REVERSE
Conditions of Approval- Permit no. : SEP94-0079
For: RICHARD RAWLINGS
Page: 2
1 ) PUD monitoring contract is required
2 ) Health Dept. required to observe pressure test, 48 hour notice to
be given.
3 ) 50 ft. setback to surface water to be maintained
„ ) MAXIMUM TRENCH DEPTH 24 INCHES
5 ) All components of the septic system are to be completely protected
from vehicular traffic or mechanical disturbance. Protective
barriers are required around drainfield.
6 ) Dose counters are required in the control panel for all drainfield
components .
7 ) Any portion of transport line under a driven way is to be double
cased or equivalent.
8 ) Asphaultic emulsion or equivalent required on septic tank and/or
pump chamber.
sep_prmt.txt 09/05/91
i •
FOR OFFICE USE ONLY FOR FINAL INSPECTION INFORMATION AND APPROVAL
SYSTEM INSTALLED BY c )\\ \ (\O C-
0
ABSORPTION AREA:
DRAINFIELD I TRENCH H aI, TANK
LENGTH WIDTH 1 U DEPTH y SIZE l
PRESSURE TEST OBSERVED - -C� -
APPROVED QS SPECIALIST LI (NCI,C._ p�1 -k1 N S DATE 4 - 4- qq•
COMMENTS: c3 1\ ( 51A
\ 600
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