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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= a 1YL / f� TO o A " O. BERNT PAUL ERICSEN•••, •1 ENSED b IGNVR EXPIRES 05/09/ Lit Q.d` to N Pee � ^t 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* i� 3 C>Q r z. 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. CC< 6 /!S /8* i� 3 C>Q r AWI - II I' i - I f! x k + P Ir I . w� 1 lrt I I I I I F i 41. + ggkkkkg§ I� •' I i �",`F � � 111 � €i I I (a. �il I I I i i I .1 h+ I I T41I I C k `b-SATE4MGE'Disposk S u0ty:o- A 4_� Street Or Division. Landmark' Lot. Block Lot Size I. Laca on -s- Lot, $Jze., L) ", 6i 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# OJI 11=7 i -l! 17 Vftkokftdsysbun? Tau- Lik"klofd Send compided rqmrt-to.- . 17 P, TIRM fl c nm MEW MWft Md Phonelonallrox A a 0- `ba,%C. g,0 OL& ! t aw f I". ��p,r1a too y` 51002 '• Q'. BER WT PAUL ERICSEN'•. t'�.. ,�. ' C SE[i •[�� �I�aNER � � } EXPNES 1 Ak _ w OV N 13 `4 Jr ._.. ��p,r1a too (SE 1/4 11 -30N -2W) UR 0 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 Search Key CMD 6: End Window CMD 7: End of Job