HomeMy WebLinkAboutSEP1975-00452Parcel Number: 002331024
Owner Mailing Address:
LAWRENCE JACOBSEN TRSTE
MARY LOU JACOBSEN TRUSTEE
3409 PADUA AVE
CLAREMONT CA917112066
Site Address:
141 OLD SCHOOLHOUSE RD
SEQUIM 98382
Section: 33
Qtr Section: NE1/4
Township: 30N
Range: 2W
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110 o
School Distict: Sequim (323)
Fre Dist: Gardiner (5)
Tax Status: Taxable
Tax Code: 751
Planning area: Discovery Bay (5)
Sub Division:
Assessor's Land Use Code: 1100 - HOUSES (single units, non-farm)
Property Description:
S33 T30 R2W I TAX 25 W/EASE I LESS CO RD R/W I I
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http://www.co jefferson.wa.us/assessors/parcel/pareeldetail.asp?Parcel NO=002331024 8/17/2005
903 E. Caroline
Port Angeles
Court House
Port Tovrnsend
OLYMPIC HEALTH DISTRICT
SEWAGE DISPOSAL PERMIT -APPLICATION
Submit in Duplicate
e-
,P75-, gc3z
Permit No.
Builder
Date /6b 7s
OWNER CEi4HR4 f�ZLi c° l+/ ADDRESS ��l0-r - "9O w E i?®itlGG PHONE o
Seel,
DIRECTIONS FOR LOCATING SITE
APPLICATION IS HI EBY MADE T0: IiTALL Na! SYSTEM ,P/REPAIR EXISTING SYSTEM. _
DRAINFIELD LENGTH LLD 11IDTH 3 DEPTH " 30 #LINES v1 SEPTIC TANK SIZE \ZS 3
DRAW A RETAILED PLOT PLAN BELOW. SEE INSTRUCTIONS. SOIL TYPE
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14K FT
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YPE OF BUILDING
NO. OF BUW0011)lBASaIENT
SITE SIZE
NAME OF INSTALLER.
DRAINFIELD LENGTH LLD 11IDTH 3 DEPTH " 30 #LINES v1 SEPTIC TANK SIZE \ZS 3
DRAW A RETAILED PLOT PLAN BELOW. SEE INSTRUCTIONS. SOIL TYPE
it
14K FT
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for FT F r
ANY CHANGE IN BUILDING OR SL'' AGE DISPOSAL PLANS, LOCATION OR SITE, INVALIDATES THIS--�C�Cc
PERMIT UNLESS PRIOR APPROVAL OBTAINED FROM THE HEALTH DEPARTMENT.
DATE OF INSTALLATION`� SIGNATURE OF APPLICAN�
AP RMVED DATE LLA > INSPECTED BY DATE
SANITARIATd'S COA'IT �IIVTS :\1 \.Z L -e -- %S TV
\o�.��.
I CERTIFY THAT THIS SYSTEM VAS DSTiLLLED IN THE MANNER APPROVED BY THE
HEALTH DEAPRTMENT DATE .
INSTALLERS NAME
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for FT F r
ANY CHANGE IN BUILDING OR SL'' AGE DISPOSAL PLANS, LOCATION OR SITE, INVALIDATES THIS--�C�Cc
PERMIT UNLESS PRIOR APPROVAL OBTAINED FROM THE HEALTH DEPARTMENT.
DATE OF INSTALLATION`� SIGNATURE OF APPLICAN�
AP RMVED DATE LLA > INSPECTED BY DATE
SANITARIATd'S COA'IT �IIVTS :\1 \.Z L -e -- %S TV
\o�.��.
I CERTIFY THAT THIS SYSTEM VAS DSTiLLLED IN THE MANNER APPROVED BY THE
HEALTH DEAPRTMENT DATE .
INSTALLERS NAME
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., .. ���.<,.,.su.S�.Mc,..,:-.i*.�u......_.,,,.,c..r%r�.%.t�st
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File Original and First Copy with 1p Application. No
Department a Ecology WATER WELL REPORT
Second,-Ceby �' ri Owner's Copy , •'
Third Copy — Driller's Copy STATE OF WASHIENGTON Permit No.:.:.
(1) OWER: f i _ `r" A i ?_ � % dress i s�0 �
Name _ .. 4-41
Ad _ __, ...._..__ _ .
(2) LOCATION OF WELL: Coun _._.. ��a2 •� �_'_'+<
t�__ _ _. _ =,4 =.4
Bearing and distance from section or subdivision `corner
(3) .PROPOSED USE: Domesu. ff lndusttrial ❑ . municipal ❑ (10) WELL LOG.-
Irrigation
OG:Irrigation Q Test Well ❑ Other ❑ Formation: Describe by color; character, size of material and structure, and
show thickness ofaquzfers and the kind and nature of the material in each
(4) TYPE OF WORK: Owner's number of wellstratum penetrated, with at least one entry for each change of formation.
(if more than one).... _.._�__ ....__. MATERIAL FROM TO
New well Q''• Method: Dug Q Bored Q
Deepened p Cable Q Driven ❑ e% " 1.4
1
Reconditioned ❑ Rotary ff Jetted Q r V e
(5) DIMENSIONS: Diameter of Well _1_
inches,.
Drilled .....ft. Depth of completed we1L-._ V11_i .--_._ ft. e`
(6) CONSTRUCTION DETAILS -
Casing installed: _•• Diem. from w.z ft. to ZLL _ ft.
Threaded ❑_ » Dia-. from ___ _ ft. to _ ft.
Welded Q� _ „ Dam. from __ : ft. to ft.
Perforations: Yes ❑
Type of perforator used_:
SIZE of or Oris
' in. b _____ g-- in.
$ 8ti
y
peri
perforations from ft. to ? ' .. ft:
perforations from ft. to —ft.
perforations from — ft. to _ _ _ ft.
V` Screens:
Yes ❑ No
Manufacturer's Name_______
Type Model No
Diam. - Slot size from _ ft. to — ft.
Diam Slot size _ from fL to, ft
Gravel .packed- Yea No Q size of gravel; -
Gravel placed from ft. to
e
Surface seal:. Yes No ❑ : To what depth? ft.
Material used in seaL._._..__k� i `O
Did any strata• contain unusable water? Yes Q No p' "
Type of water? Depth of
Method of sealing strata
(7) PUMP: Manufacturer's Name__:.__..-_
Type:.
(8) WATERLjjELS: :. Land -surface elevation -`�. t
above mean sea level.... _0: _ ft.
Static level b ft. below top of well Date_' ftp
Artesian pressure Dw. per square inch Date .:
Artesian water Is controlled by _. _
(Cap, valve, etc.) -
(9 WELL TESTS: Drawdown is amount water level .is
) lowered below static level r -3 `
Work started....�.._......,:.._......+, IJ �' '. Completed -
Was
Was a pump test made? Yes Q No to ' rf yes, by whom?--_-__.._...
Yield: gal./min. with ft. drawdown after hrs. WELL DRILI"S STATEMENT:
This well was drilled under my jurisdiction and this •report is
•• • •• true to the best of my knowledge and belief.
Recovery data (time taken as zero when pump turned off) (water level a :
measured from well top to water level) NAME... '
.... � ' ................
Time Water Level Time Water Level Time Water Level
— -
(Person, hrm or corporation) > ?(Type or print)
- .
............... :._......-- ..._�._ ... ............... Address....`.......
..._ .». _
Date of test [S1gIIed]... ; _
Bailer test_._M___.gal./min. with�..._.....ft. drawdown after __ _hrs.. ` "" '(Welt°Driller)
Artesian flow g.p m. Date --
T
ate.._..
Temperature of water-......: --.. Was a chemical analysis made? Yes Q No A � License NO.a _... 1 .:...::....... _-.'Date.:_ _. '.. _-
(USE ADDITIONAL SHEETS IF NECESSARY)
S. F: No. 7356—OS—(Rev. 4-71). 3
i
I,• I
• • 0 of
Water Right Claims, Registration
WaterfWht Claim y"<r"9av
Name Kenneth L. Huma, (Short Form)
Address Routs #2, Box 352,
"quim. Washington- Zip Code 98382 Phone No. 797-7431
1) Source from wh ch the right to take and hake use of water is claimed: ❑ Surface Water Ground Water
ft -surface _
water, -please -:indicate source; give name if known:..'
(River, stream, lake, pond, spring, etc.)
2) Purpose(s) for which water is used:
®,Damestic I Stoekwatering [2 Irrigation (lawn and garden) ❑ Other Use (specify)
3) Legal description of lands on whteh ovate is used: the South 315 feet of the Korth 1575
of . the East =Ha of` the' Tast Half of the Northeast Quarter of Section
33- ALSO the Smuth 315 feet of the'North 1575 feet of the Weft 30
feet of Section34•: ALL= in Township
30 North,
_Rang e 2 West, W. M.
Situate in the County of Jefferson, State of Washington.'
y
Zf'locatedwithin :the limit$ of a. recorded platted property:
Lot Block - of
{Clive name of plat Or adtirUon)
lit -addition,; please indicate Sec T E/W, W.M.
County 3t%°which lands`are located j ,eff er4,+t„tnt
I hereby swear that the above information ls,ttue and accurate'
DO NOT USE THIS SPACE to the best of my knowledge d belief
The filing of a statement -or claim does not constitutean adjudica�
tion of any claim to ft, right:to.t[se of Waters',as between the water X
use claimant and the state Or -''as between one ter more use claimants
and another 4 others This s cicnowledgment ;oqstifiaes receipt for nat,. - s
thefihng tom. r � _
If, claim filed by designated `,.represeatatt�ez nt or type cult
Dalai Regtstemd This has b A dss fined name and marling ad ltcss cif went be1oV�
�- Water Iitght C}aim Registry No
^01.
a Vu
❑ AdditiatEal i�f�tttt til tEt 114 ttli► t
i well tsnstr"stlatt le 1►plhl� t 5
fd.�p l� tR •1, 7 � � � i A i _ y z � 1 is
J.L. Jacobs. Inc.
221-C South Peabody
Port Angeles, WA 98362
(206) 452-4592
(206) 385-3521
Fax(206) 452-1385
Jay Jacobson
3619 North Garey Avenue
Pomona, CA 91767
Date: 9/16/92
Present on-site:
1 �
SEP S 7 1992
Customer No: 92345
Michael Boardman - J.L. Jacobs Inc.
Jerry Jacobs - J.L. Jacobs Inc.
Celia Kadushin - Jefferson County Environmental Health Dept.
Project Site: 141 Old School House Road
On September 11, 1992, I performed a Soils Analysis to determine
the type of on-site sewage disposal system that would be required
on the parcel described above. Copies of the soils test pit log
and pit location sketch are enclosed. Under current State and
County regulations this lot will require a Conventional Septic
System and the system can be extended.
My fee for designing a Conventional Septic System is $325. Please
submit this amount to J.L. Jacobs Inc., when you are ready for me
to proceed with the design.
The Jefferson County on-site sewage disposal fee is $120. Your
check should be made out to Jefferson County Environmental Health
Department but forwarded to me to be attached to your permit
application. I will complete this application for you and submit
it to the County along with your system design.
Use the enclosed pit location sketch to show the proposed location
of your house, driveway and any neighbor's well within 100 feet of
your property. Please include the number of bedrooms this design
will support. Please return this sketch along with the two checks
discussed above when you are ready to proceed.
Customer No: 92435
If you have any questions please contact our office at 452-4592.
Thank you for using Jacobs, Inc.
.ncerely,
e y Ja obs, Certified Designer
Michael Boardman, Certified Designer
cc: Celia.Kadushin/Jefferson County Environmental.Health Dept.
File
RECEIVED
SEP 171992
JEFF. C UUr4TY
HEALTH DEPT.
i
L��``-r-mss%t' rG�,� - �•rhy 1 F-- r,�c..:
o , 5'r It _
sty. C2!2ne
J6 - C-1-7
e� •yv ds ✓GbYri cJ�� .
►t�°It-4z gfc +v 6, to�2cas�C/r� �C i� w "j-
d� B2+°4E
Date: 9/15/92
Customer No. 92345
TEST PIT LOG ;
FOR ;
JAY JACOBSON ;
RECEIVED
SEP 17.1992
JCrF. COUNTY
HEALTH DEPT.
Prepared by: J.L. JACOBS INC. Test Date: 9/11/92
221-C S. Peabody
Port Angeles, WA 98362
(206) 452-4592
Project Site: 141 Old School House Road
Test Pit #1
0" - 49" Gravelly sandy loam, slightly compact
49" - 60" Gravelly sandy loam with faint mottling
Roots to 60"
Test Pit #2
0" - 48" Gravelly sandy loam, slightly compact
48" - 60" Gravelly sandy loam with faint mottling
Roots to 48"
Test Pit #3
0" - 48" Gravelly sandy loam, slightly compact
48" - 60" Gravelly sandy loam with faint mottling
Roots to 48"
Test Pit #4
0" - 48" Gravelly sandy loam, slightly compact
48" - 60" Gravelly sandy loam with faint mottling
Roots to 48"
A P i
-rat lot r (.-ren oe') sKt%7 c t+
RECEIV ED
SEP 171992
JEFF. cQUNTY
HEALTH DEPT.
l A-
tL
Row P
JEFFERSON COUNTY HEALTH06PT. .• Receipt No. //J�
CASTLE HILL CENTER
615 SHMIDAN Fee:0,(. 0, 6i.D
PORT TOWNSEND, WA 98368-2439
Date: Ij
208-385-9430 r Z
RECE1VEDc
EVALUATION m noIVIDUAL STAGE DmO m sySm Am/oRwm= smmy
/ AUG 2 8 1992
Information Reggessted: V Individual Sewage Disp--%mal System.
Water Supply P►.;blic Private JEF1-. t-UuNl Y.
HEALTH DEPT.
Applicants Name �'A 11 Mailpletr�c7 rt To-
o
o
Owners Name' A I e e-r�e n51$11�
Address �.
Phone: Nimber of bedrooms
Previous Owner (if Knr-wn)�,+� �'�-/ a/*- ZYear Installed fr-� -7�
Legal Description: Section�`� � hip �0__ Rae A w
Street Address /lv/
V/ _ n ,���>_ Ai
SEWAGE DISPOSAL SYSTEM*
Permitted system yes no
Installed prior to permit requirement yes no
Sewage noted on ground at time of inspection* yes no
House is unoccupied therefore an evaluation of drainfield performance is
not possible at this time.
A review of our records indicate that this system was designed to
service a bedroom residence. This system is not considered
adequate for a bedroom residence unless it is sized per current
regulations.
Septic tank sho ad be pmmped if not done within past 3 - 5 years.
l^-5*R i1;i- 4
Well casing 12" above grorund yes no
Sanitary seal in place yes no
Well 100' from drainfield yes na
Water sample taken yes no
Sample results
co®nents:
See- ✓ Mr$
t(es; v .
yE-�C„i"r7- Seko�--Y- sys&m fi�,,n G, -2 M 4
Date 1-Y-72- Time
Environmental Health Specialist
This report does not constitute a guarantee, either written or implied, that
the system will contime to function properly. This report ccnstitutes a
summary of findings only.
EESFORM
gym.n.��axy < : ,:d7".siLo:# rxys'S u a yak"ea c_�Sr6cL +: �aJi a.u;r, a7A
JEFFERSON COUNTY HEALTH DEPARTMENT
MULTI -SERVICE BLDG., 2ND FLOOR
802 SHERIDAN AVE., PORT TOWNSEND, Wk 98368
(206)385-0722
INSTRUCTIONS FOR EVALUATION OF EXISTING SYSTEM APPLICATION
1. Please complete the information on the top half of the application
form. Include a drawing of the plot plan and map to the property on
this form.
2. Uncover the septic tank. Uncover the inlet and outlet inspection
ports and be sure the inspection ports are loose, so inspection of the
inside of the septic tank can be made. Provide copy of pumping
receipt if septic tank pumped within the last 5 years.
3. If a water sample is involved, please allow one week from the time of
sampling until results are ready.
4. Unless otherwise noted on the form, all reports will be mailed back
to the applicant when completed.
5. Fee schedule: Sewage Disposal system $60.00
Sewage Disposal and Water $80.00
Water Sample $65.00
0
EESINSTR.91
Ce
S-33 T- 30N R -2W
Date Approved: 11-6-75 Gardiner area
#-#3909 5F -s