HomeMy WebLinkAboutSEP1973-00016Jefferson County Departnrmat of Community Developmerd `k`: ' s'
624 Sheridan St., Port Townsend WA 98368, (360) 379-4450
SEPTIC PERMIT APPLICATION
vIM"MW—���lLr?.7IM
MAILING ADDRESS
PHONE Area Code ( 360 Yox, lal- it s oei l�az-��
SYSTEM DESIGNER `&.YrL.+ & ( G -Se ,
LEGAL DESCRIPTION: Section Township Range PARCEL #
Subdivision Name -odnp- & I O CAM Division 1Blc _I Lots) 15
SITE LOCATION I 1 \I Cft) k--" -U)k Zip Code
SOURCE OF SEWAGE Reskleritial _ fit(_ Residential ADU Commercial Community
TYPE OF WORK: New Redesign _ Upgrade Repair Partial (tank) (drainfield)
Eamon Reserve Area _„?,QModification .
Conventional. )(_ AitemaWe Drairfieid Length. 9g, 17-0 � ft. Trench Width 4,1_1
Number of Gallonsklay ,�Trench/Bed Depth EIA, un. Number of Lis z -
Site Size ,11. CM Septic Tank size X14. Std 4- gal. Pump Chamber s¢e = . tnal.
Water Source: private putft Sora type (ATTACH SOIL EVAL.)
Previous evert: yes I no #I� Q �' 14- Application Rate gaIlsq.ft/day
TYPE of SYSTEM �•�� ��ln �+ L..
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 assare you of any oth®r Couxrty, 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 seemly judged by the rules and laws In effect at that time.
Ownw slgnaitinte Date
i FOR OFFICE USE ONLY
l 2-1 tz [dS PARTIAL ASBUILT tdAl. S
APPROVED
PRESSITEST PUDE
Fire D sdma Dbw zee
Date . --2- F� S
60
Rec 0 cue # SEP I
Septic Permit Application Form_05-10-04_pdf
JEFFERSON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT
621 SHERIDAN ST., PORT TOWNSEND WA 98368 (360) 379-4450 _
SOIL EVALUATION
PROPERTY OWNER
SYSTEM DESIGNER r1 t E10e-sev,
LEGAL DESCRIPTION: Section _L7- Township �� Range jo Parcel # j?OD l (�
Subdivision Name_ Division_t Block i Lot(s)
Date Logged:_ . _ Logged By= 6r(CSem
Include soil textural characteristics and the depths at which significant changes occur. Be sure to include depth
where mottling or impermeable layers occur.
SOIL LOG #1
L_to I2. in. (6r. L.C_ 7: +.f
0, to SI in. 74-n 4 'r� 4p . T. �4.
3Z to > in. K*ttf4s _
to in.
Anticipated water tablet j in.
Roots to ¢i I inches
Health Dept., Comments
SOIL LOG #3
to in.
to-in.--
to-in.-
to-in.
oin.toin.toin.
Anticipated water table in.
Roots to
Health Dept. Comments
SOIL LOG #5
to-in.-
oin._toin.to
to-in.-
to
in.
inches
to in.
Anticipated water table in.
Roots to inches
Health Dept. Comments
SOIL LOG #2
C5 to I-;- in. Or. ;.L
z to_j�,_in, t. V .-�2. C -)
to in.
to in.
Anticipated water table in.
Roots to .2e inches
Health Dept. Comments
SOIL LOG #4
to in.
to in.
to in.
to in.
Anticipated water table
Roots to inches
Health Dept. Comments
SOIL LOG #6
to in.
C? -to -in.
W to in.
to in.
9r
Anticipated water table in.
Roots to inches
Health Dept. Comments
H:UNF0HLT1IS01L.FRM1=
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BERNT PAUL ERICSEN•••,
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EXPIRES 05/09/
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Gl.57 18..7' ._,.
"0 E. aro]:it�e OLYMPIC HEALTH DISTRICT Permit No.
Port Angeles SMIAGE DISPOSAL PERMIT APPLICATION
�/� ubmit in Duplicate._. Builder
Court House
Port Townsend �C9 P.Fo _2 3i� Date
�r
Oti�NER ADDRESS \ ` L PHOS
DIRECTIONS FOR LOCATING SITE R�
APPLICATION IS HEREBY MADTO: INSTALL N°► SYSTEMR EXISTING SYSTEM -
��,.�-��� _ c sit
DRAINFIELD LENGTH_\Q�►IDTH DEPTH Ag ll#LINES_\_____LSEPTIC
DRAT
PERMIT
DATE OF INSTALLATION SIGNATURE O�
APPROVED DATE NSPECTED BY
SANITARIAN'S COIR411ENTS:
I CERTIFY THAT THIS SY - 'JAS IATS .�LLED IN THE MANNER APPROVED BY THE
HEALTH DEAPRTMENT ' DATE
T T II T T T1 n n n ar.
CC< 6 /!S /8*
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RE OF BUILDI
NO. OF BEDROOMS
BASEMENT
SITE STZIJ
NAME OF INSTALLER
DRAINFIELD LENGTH_\Q�►IDTH DEPTH Ag ll#LINES_\_____LSEPTIC
DRAT
PERMIT
DATE OF INSTALLATION SIGNATURE O�
APPROVED DATE NSPECTED BY
SANITARIAN'S COIR411ENTS:
I CERTIFY THAT THIS SY - 'JAS IATS .�LLED IN THE MANNER APPROVED BY THE
HEALTH DEAPRTMENT ' DATE
T T II T T T1 n n n ar.
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Street Or
Division.
Landmark' Lot.
Block Lot Size
I.
Laca on -s- Lot, $Jze.,
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S Ys Own
10
Address
r
Tele �;ho he N umbdliri
Permit,: ous owner)
Date llssued-
'.
I.
4 A
Ins 11, er
umber of P46 e Served"
Average PI
Date Installed'92
Number of Bedrooms
.-I
Time In-Servicd, (years')
-.0tthes Wa04tr
9ES
Septit Tank- Pumped
SLAW Na
ftoW
Dishwasher,,
N6
XN'
YES
Months/Yeas Res14ende ccupled?-'.
# of Mon -0
Garbage' bis'posal
No
YEISL
7.
.777
-ly'pe`b'f
cover over drainA41d-
(i.e et
gross landscaping
Evaluation of an Existing Onsite Sewage System .
�#nspectedby
Date of inspection
L . —��_ -
-z: 'J
Wafter Suaaly Olin stOWis being t
only if water'ested m this evaluation)
Sample was taken Yes SarnPte Results
Welt' casing IT adv® -ground Yes. –
Sanitary Seal in p - Yes : No.
of�e _— onsite Nance of System.
Public ortsit
Individual: onsite _yam,, if nom; d'tance,
Is wen more than 1W to UWR--,rrfiekUdisposalcomponent
Is wen more than W to tanks and effluent trans it Irene no. if n ; disf -distance.
ONSITE SEWAGE
# BedroonWgdons per day indicated In County Health Dept. records for this case
�1- Seatic Tank .. ,.
Tank size -7 50 gal.-�d-4Mgle cte Wt11Wd -- lac ntP&jg r+ -4P _ material
Riser th grade on ajW ves_>�_ rro. Riser to grade on outer --yes-4--m
Condign of tank %& repair,
1st comp. Scum (top kraim•) In. sludge (boMm 10yer) In.
2nd corm. scum In. sludge in.
Was ground water, observed lea wV Into cmc ? ____,yam _.-- )n no
U yes, where was water observed? e C,Conc ete)
Condition of baffles. UMet^ -�A a°od needs repair ' P•-�� I (Pd
outs repair '431n I1� `�It materiaP(PYC,c�rtcxete)
Screened outlet.ono r.Ye% n ----- dean --------dirty
Septic tank needs to be pumped (per Jeffers°° County code 8.15.150 (1) (b)),_. Y98_X _no
Eftent level at cult (mark lievel on rhde) if aluent is below the outlet indicate
when toric was lea pumped:
( eg: )
Does system include a pump? ________ yes If yes, complete the rod section �A__ no (if no skip to section 3)
#2 - Puma Chamber
Tank size gaL __—._ - Material. R to grade? --- Yes no
Condign of tank ! mood needs reps&,
In.
Solids In Tank (see 8.4 1fl0) yes:
na scum a� sludge
Was Groundwater observed leaking. Oft tank ? yes no
if yes, where was water observed?
Screen around pump?
vee • rw •Steroid aurounal pump? v� �.
Ems! Corm
Pump opwerawo Vee
Huh water alarm Win$ yes no, if no, describe
Elm Panel cond'iti'on good needs repair, describe
pump cycle drawdawn arches. Tana farpump.cy m is -ono
Tirrrer Settir►gs on , mint n off Fids sec ured— vim -
Pte# or Parcel
Evaluation of an Exlsfing onsite Sewage System
03 -DralnMd
Appropriate Vegetn in areaW. Descxibe vegefptlon_ d ,
Indications of surfating sewage (d*& one) yes If Yes, B robe and diagram on plot.plan
ono .. .
drabftM area is overgro�m and not pbservable
Son of parich4drift In area vesno rams area unlcrown
Ground settling or Ston Yes
_,______..,-dovrnwwm/not
observaWe
MmAoring Port Obserivations (if present):
Re"a l Heart ,,,_,_,,,.,,yes, tt of fer ono .
Porafg In trench ves, # of Inches of ponded effluent _no
Rep* area Is? Ave&** as shown on pwn* A _,None evaluated o r showm on permit
Addendum Is attached for svaluatlon of Tint UnR or detalled evaluation of drak tell ,,.., YO$44- .no
C NU (attach add al shoot ff necessary):
Was a System Problem Itientlfied? Yes If Ye% what seortbn #. _,__ _,No U . .
This report on the existing onsite sump system Is valid for the pennitted or historic (if inked prior to permit
requirements) use of the system only and does not cqnsdlute assuiance of hidme County approvals (sem as WWMg
p mft) on this parcel. Any Mm application wig be judged separately by. the rules and laws In MW at that horse.
I csrdfy that #re information provkledis based on a review of Courtly remft and my drect observations at ft torn of
hrspectian. ��� ����, • � � � _ � .
Deft
No guaraffte of futuro waft sewage system perbnonce Is imps or grentmt basest on Me loWn lion contained in
#lits report.- Thi report crcx"lutes a summary of titin p only
trzi sit' an b Date
-7- :2�
K3ftfto Owdbl SOWNP 24baftm OMS) RomL '1%88'7
ao
Dann obdwbwkofthis dmwta plat show on 111,01,11:111,11M of: CmdL2
SUROW86 n -1 a I - 16 Sopft Tadw,, WWI% oft OR allmb a potpim �Qqq
-AMPL-e-
amwum Name.
ALL SPACES UM WE FLUM RL
N infotmatlon is not available enter PM or not" WA).
&&%man Of W -oft wow "Iftm
O E""m or *W" Wour
13 &MuMon of m -aft m*We & *Mft waW
Reason ftEvaWaSm
El ftu*w owaft and Montt" mweo*m
0 ftd-kAft Un"m
13 conOw a Perm*
01 &Aft Pam* Rv#Wm anftr no sqft Mat an ft
13 ogm, =own
Tax pWjW q 3 18,00 1 J,5 Pennftled Systm &_ym FP #SEP 73-ooi&
&6Wslon. Mdslon, Bkx* mW Lot(s) N&, 6 gaz4, eol on" -ht' 0 1 ---.b I Ak-
Lot Slm—jLsjg —*/-Acres'or Dknwmbm______.X_
ll�� Owner 4
Slte
OwnerPhone#
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Jefferson County Department of Community Development ,7
621 Sheridan St., Port Townsend WA 98368 (360) 370-'AAI%(�("`��
MONITORING INSPECTION CERTIFICATION tQe�
The system serving 0 ty .G�Lc* be 'I on
parcel # ,
recently inspected on
2. -`(-o t
Jefferson County Code 8.15.150.
permit # SAP73 —/G was most
by 8AL IJP , as specified in
The above referenced system is in compliance with the Monitoring/inspection schedule
identified in Table 1 of Jefferson County Code 8.15.
1:4 See report completed I ���ll01 for information on the condition of the
onsite Y
sewage system.
FREQUIRED OR RECOMMENDED REPAIRSIMODIFICATIONS TO THE SYSTEM ARE
LISTED ON THE INSPECTION REPORT DATED . Failure to
complete repairs or modifications to the system as listed on the report may result in
premature failure of the system.
The next inspection required for this system is in 900
Table 1 requires that this system receive an inspection:
Annually
Every 3 years
Every 6 years
Other as specified in the sewage disposal permit conditions -
An inspection will be required at the time of sale if the system does not comply with the schedule set
by Table 1 as described above.
The above information is based on review of the file and does not imply or grant a guarantee of
current or future system performance.
Signature of Jefferson County Employee
It cin heath Iinda.GU FORMS MONITORING INSP17CTION CGRTIFICATION.doc
l kz
Date
ENVIRONMENTALLY SENSITIVE AREAS REVIEW
SEP73-00016
Owner: BERT J HOLVERSON Site Address:
231 VICTORIA LOOP 231 VICTORIA LOOP
PORT TOWNSEND WA 98368 PORT TOWNSEND WA, 98368
Parcel Number: 937800115 S -T -R: 12 -30N -02W
Legal Description CAPE GEORGE COLONY DIV 1 BLK 1 LOT 15
Total Acreage: 1 Fire District: 6 Planning Area: 2
Flood Map (FIRM) Panel No:5300690135B Flood District: School District 50
WATER SUPPLY UTILITY: Service Area PUD:
[ ] Assesoes Map
[ ] Forest Lands: Adjoining Forest Lands:
[ ] ESA'S
Wetlands:
Aquifer Recharge Area:
Flood:
Erosion:
Landslide: h
Seismic:
Fish & Wildlife:
Stream Type: NZ
Shoreline Designation:
Flood Certificate:
Violations:
Require Declaration of Restrictive Covenant to meet minimum land area
Recorded Date of Subdivision: <5yrs=Plat Conditions on plat or Old Ordinance
PARCEL TAGS: No parcel tags found for this parcel.
Associated CASES status issued finaled description
SEP73-00016 P 9/10/197 9/19/1973 EES BY ENVIROCBECK 12/04/01
1AF_MLT ESA_Review.rpt November 23, 2005
Jefferson County Department of Community Development- se Only
6214 Sheridan St., Port Townsend WA 98368 (360) 379-44 p
DEC - 5 2001
Evaluation of an Existing Onsite S ag System I=
P1
Attach plot plan showing location of: Structures, Drainfiel T nk,ODS cpt
ALL SPACES MUST BE FILLED IN EXCEPT AS NO,f (� UA—DEVE 0
4-
Is not available (NV) or not applicable (N _
" -- - ,- Case #
Type of Evaluat Cp 4 001 Reason for Evaluation
j) ❑ in & M Inspection
Evaluation of on-site sewage syst Transaction
❑ Evaluation of Drinking Water �E�� omplete a Permit #
❑ Building Permit Review and/or no septic permit on file
❑ Evaluation of on-site sewage & Drin ater ❑ Other
Date of this inspection ���� Inspected by
Owner or representative, report to: Name/Address/Phone i.�.
Current owner Laim aTka4. VEWATL Site Address Q'M cro9aft �6-w
Owner Phone # 253fr-
7 ���1 Previous property owner name (S) if known F�E
Parcel # `3-7 8001 kG Subdivision, division, block and lot(s) E41�ces &. Z" i 191Lt V LOT Is
Permitted System_ yes no Permit/case #�3�1«
Date system installed -47-111) Age of dwellin(oq
# bedrooms -louse°occupied —yes no, vacant how long? hMUT l
Designer V) ,3 Installer V4 1 ° u30SE%/
Water supply
Sample was taken Yes ' No Sample Results
Well casing 12" above ground Yes No Sanitary Seal in place Yes No
Public: offsite onsite. Name of System
Individual: offsite onsite
Is well more than 100' to drainfield/disposal component _yes no, if not, distance
Is well more than 50' to tanks and effluent transport line _yes no, if not, distance
ONSITE SEWAGE SYSTEM
#1 - Septic Tank
Tank size. 4Q:2Q+ gal. single compartment two compartment 0 c,&,gR—c L material
Riser to grade on inletves�C no. Riser to grade on outlet ves X no
Condition of tank k good needs repair, describe
1 st comp. Scum (top layer) V ` in. sludge (bottom layer) \6 in.
2nd comp. scum in. sludge in.
Was ground water observed leaking into tank ? ves _X _ no
If yes, where was water observed?
Condition of baffles: Inlet YC good needs repair material (PVC, cre
Outlet: X_good needs repair material ,concrete)
Screened Outlet --X__no _yes, condition clean clogged/dirty
Septic tank needs to be pumped (per Jefferson County code 8.15.150 (1) (b))X_ yes_ no
Effluent level at outlet (mark level on circle)
If effluent is below the outlet, indicate
when tank was last pumped:
eg:
Onsite Sewage System Inspection Report Page 1 of 3
01
On
TVA
oil
1.
Low!
Doe's system include a pump? yes_ C�_ no If yes, complete the next section.
#2 - Pump Chamber
Tank size gal. Material. Riser to grade? ves no
Condition of tank good needs repair, describe
Solids in Tank (see 8.15.150) yes no scum in. sludge in.
Was Ground water observed leaking into tank ? ves no
If yes, where was water observed?
Electrical Components
Pump operating ves no, describe
High water alarm functions ves no, if no, describe
Elec. Panel condition good needs repair, describe
Pump cycle drawdown inches. Time for pump cycle min/sec.
Timer Settings min/sec on min/hrs off Floats secured ves no
#3 — Drainfield
Appropriate Vegetation in area XQ fres no. Describe vegetation 6L:rT ��� K, 0AA-6s
Indications of surfacing sewage
T ves , If yes, describe and diagragm on plot plan
no overgrown/ of observa
Signs of parking/driving in area ves -K no
Ground settling or erosion ves )Q _no overgrown/mgol5sen�
Monitoring Port Observations:
Residual Head ves, # of inches no
Ponding in trench ves, # of inches of ponded effluent no
Repair area is adequate 4 limited none available, describe
#4 - Treatment Unit (Sandfllter, Proprietary Device etc)
Appropriate Vegetation in area ves
no. Describe vegetation
Indications of surfacing sewage
ves , if
yes, describe and diagram on plot plan
no
overgrown/not observable
Riser to grade? ves
no
Signs of parking/driving in area
ves
no
Ground settling or erosion
ves
no overgrown/not observable
Monitoring ports in good condition
ves
no none present/no port found
Monitoring Port Observations
Residual Head ves,
if yes, # of inches no. If no, notify Owner immediately
Ponding in trench ves,
if yes, # of inches of ponded effluent no
Electrical Components
Pump operating ves
no, if no, describe
High water alarm functions
ves
no, if no, describe
Elec. Panel condition good
needs repair, describe
Pump cycle drawdown
inches.
Time for pump cycle min/sec.
Timer Settings min/sec on
min/hrs off Floats secured yes no
Permit # -I "�>— OCAto Owner Name 'pky
H:\env_healthUinda\GD\FORMS\2000Onsite Inspecdon Form1-M.doadot 2 of 3
COMMENTS (attach additional sheet if necessary):
SEE ATTACHED COMMENTS
AND ADDENDUM
Was a System Problem Identified? Yes if yes, what section X No _
1 certify that the information provided is based on a review of County records and my direct
observations kNa
t e tim of i spection.
1 x.0401
a/Signature Date
No guarantee of future performance is implied or granted based on the information contained in this
report. This report constitutes a summary of findings only.
Section below line to be completed only by Licensed Designer, Professional Engineer or
Health Department staff
Complete this section if system is permitted but did not receive an OK to cover or final approval OR there was no septic
permit on file.
Describe materials observed in drainfield construction:
D -box present yes if yes, material no
Drainlines rigid PVC corrugated flex pipe clay tile
concrete the seepage pit or cesspool other
Drainfield dimensions length width # of drain lines
Do observations coincide with permitted system requirements/conditions? _yes no
Soils in area of drainfield evaluated? Yes no
If yes, describe soil profile below and identify location on plot plan.
What is the vertical separation from the bottom of the drainfield trench to a restrictive horizon? Inches/feet
Comments (attach additional sheet if necessary):
Permit # 3— 001(4 Owner Name
H:1env__healthVinda\GD\FORMS\2000Onsite Inspection Forml-9-0.doc.dot
3 of 3
COMMENTS SHEET
Date -120401
Address- 231 Victoria Loop Rd., P.T.
SEP 73-0016
SEPTIC TANK
A- Risers are mandatory on next inspection.
OTHER
A- The house was unoccupied so no assessment of drainfield could be made.
B- The original permit on file indicates K2+ guest rm" under no. of bedrooms.
ENVIRO,vootHECK
1612 Hastings Ave. W
Port Townsend,, WA 98368
PH 36Q79-9400
Dorm klaolk-ok
As'k \ zs\CNOVAA' ���
oHECK
, Ave. W
WA 98368
,r.6'17 'VSdok\g-
•• DP�� ��.o�ol -SSP `� �j--c�l�
ADDENDUM
Enviro Company Disclaimer
Based on what we were able to observe and our experience with on-site wastewater technology, we submit
this Sewage treatment Inspection/Evaluation Report based on the present condition of the on-site sewage
treatment system. Enviro Check has not been retained to warrant, guarantee, or certify the proper
functioning of the system for any period of time in the present or future. Because of the numerous factors
(usage, soil characteristics, previous failures, etc.) which may affect the proper operation of a septic system,
as well as the inability of our company to supervise or monitor the use or none visible areas of the system,
this report shall not be construed as a warranty by our company that the system will function properly for
any particular buyer. Enviro Check disclaims any warranty, either expressed or implied, arising from the
inspectionlevaluation of the septic system or this reportlevaluation. We are also not ascertaining the impact
the system is having on the groundwater or environment.
Enviro Check
1612 Hastings Ave. W
Port Townsend, Wa. 98368
360-379-9400
I acknowledge that I have studied the information contained herein and that my assessment is honest, done
in accor with Jefferson County Ordinances, and to the best of my ability, correct.
ame TitTe
Comments (notations, repairs, recommendations)-
SAMP' MG (Septic tank) MEASUREMENTS
Date- Counter S
PH Result ur MOM
DO
r -
DO Result- Water Uas a (Ave GPD) Meter-
Temo• Result- Squirt Heig,(i n feet)-
ENV/ROvoOtHECK
1612 Hastings Ave. W
Port Townsend, WA 98368
PH 360-379-9400
v
Screen: 01
Parcel # 000937800115
REAL PROPERTY MASTER
Geo Cd 300212302161
CAPE GEORGE COLONY DIV 1
BLK 1 LOT 15
Mode: INQUIRY
Auto Roll: OFF
Nbad Cd 5520
* Taxpayer Cd HOLV 2800 HOLVERSON, BERT J
T/P Chg Dt 11/20/2001
* Title Owner
T/P Chg Usr JODI
Tax Code 0161
Status TX TAXABLE
Land Use
1100 RES -SINGLE
Affidavit 93491
Vol/Page /
C/U Code
S/C Cd
Legal Doc QCD 11/15/01
Amount
0TH
COMPLETE ADDRESS
WINDOW
Taxpayer
HOLV2800
BERT J HOLVERSON
ELSE M HOLVERSON
9225 WARWICK DR
DESERT HT SPRINGS
CA 92240
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