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HomeMy WebLinkAboutSEP1972-00078y�e#%ryson County Department of ComrnunDevelopment :. 62-1 Sheridan St., Port Townsend WA 98368 (360) 379 -4450 Evaluation of an EaKlsting Onsite Sewage System (EES) Draw on the back of this sheet a cu nt plot plan showing location of: Buildings, Drainfields, Septic Tanks, Wells, etc OR attach a current plot plan identifying these Items. oatedj:Z � ( - Fee d Recptl Check-201 3S case # r) ALL SPACES MUST BE FILLED IN. If Information Is not available enter (NVj or napplicable (NA). Type of Evaluation Reason for Evaluation ❑ Routine Operation and Monitoring inspecdon t/Evaluafion of on -site sewage system -,Z Real Estate transaction • Evaluation of drinking water ❑ Complete a Permit # ❑ Building Permit Review and/or no septic permit on file • Evaluation of on -site sewage 8 drinking water ❑ other, explain Date of evaluation /d ° 16 ° 0 Inspected by zr.-), , dz6z 6 z Tax Parcel # ,(®(�, -/33 ' �� Permitted System yes no Permit/case # SEA Subdivision, Division, Block and,t_ot(s) N-A Lot Size -j rS_, , *Acres or Dimensions X Current Owner +� S Site Address -3 0-2- 07!L HL" /0/ Owner Phone #An JjeA1eYf--,J@1- 16 d 7q 0 9-f ®-7 Previous property owner name(s) - (NN if not Directions to e 0-r Date System Installed ° 7 'A Age of Dwelling # Bedrooms_ House Occupied __ _yes___-V_no, vacant how long? Who installed system? A •`C k r ll S o a NOV - 2 2009 Send completed report to: Owner Name Mailing Address Phone /email/fax Realtor or Other Representative Name Mailing Address Phone /emai EES Evaluation Farm ©7- 30 -04 _pdf page 1 of 5 :.1nclie :tho:'fottowm pl:plan. we ei'Property boundaries M" Names of adjacent streets & / Driveways and parking spaces p Surface water (ponds,creeks, etc) V/ Buildings(residence, sheds, garages, etc) v. Wells w-' Septic tank �Y rainfleld (enter N/V if unknown) VI Arrow Permit # or Parcel # 6 19 z ,— i 3 3 ' ®Q 9o7lsolo$_pdf page 2 of 5 Evaluation of an Existing Onsite Sewage S stem _ sJ �CO ✓A f, 9, . \.. :fit '�...: tq � °' }Y ~•.��b: Fes. Date of Inspection ! Inspected by supply (fill in only if water supply is being tested in this evaluation) Sample was taken Yes No Sample Results Well casing 12" abo a gr d Yes ______No Sanitary Seal in pi Yes________No Public: ite 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 SY STEM S G �g # Bedrooms/gallons per day indicated in County Health Dept. records for this case � /-- ✓' �' � j G Ta - Septic _ / Tank size (�___. gal. 'V single compartment � compartment n G r e t, C., material Riser to grade on inlet es_�___^___ no. Riser to grade on outlet as no Condition of tank needs repair, describe 1 st comp. Scum (top layer) rin. sludge ( ottom layer) °7 _ in. 2nd comp. scum in. sludge—A/1' —in. Was ground water observed leaking into tank ? _yes _ no if yes, where was water obsg�vad? Condition of baffles: Inlet �/ ood______ needs repair material (PVC,C(PVC, o Outlet�ood needs repair material (PVC,concrete) Screened Outlet no , _yes, condition _ clean _clogged/dirly Septic tank needs to be pumped (per Jefferson County code 8.15.150 (1) (b))� yes _no C 16-6 - 09 C4, ri Effluent level at outlet (mark level on circle) If effluent is below the outlet, indicate when tank was last pumped: Does system include a pump? yes If yes, complete the next sectlon _r V __ no (if no skip to section 3) #2 • pumg Chamber Tank size gal Material Riser to grade? ---Yes no Condition of tank eo&`---, needs repair, describe Solids in Tank (see 8.1 no scum in. sludge in. Was Ground water o rued I i to tank ? es - no NOV s 2 29009 If yes, was ob di /d ed Screen around pu p? no , _yes. co ditlon _ dean dirt og9 Shroud around pu yes Electrical Componen V Pump opere ing o, describe High water alapin functions _____ Yes no, if no, describe Else. Panel condition — gam___ --! needs fepair, describe Pump cycle drawdown _ inches. Time for pump cycle . min/sec. Timer Setlings min/sec on min/hrs off Floats secured: d83� ­­no Permit # or Parcel # l J3 Q page 3 of 5 ,gvaluation of an Existing Onsite Sewage System U7 /30 /04_pdf #3_ Drainfield % �� Appropriate Vegetation riate V etation in area yes no. Describe vegetation �✓ - Indications of surfacing sewage (check one) , yes , if yes, describe and diagram on plot plan am 1 1L., drainfield area is overgrown and not observable Signs of parkkWddving in area ves�no rainfield area unknown Ground settling or erosion ves no overgrown/not observable Monitoring Port Observations if present): Residual Head yes `�--�V # of inches no Ponding in trench AIV yes, # of i ches of ponded effiuer►i _,_,__no Repair area is? ,Available as shown on permit one evaluated or shown on permit Addendum (page 5) is attached for evaluation of Treatment Unit or detailed evaluation of drainfleld yes no COMMENTS (attach additional sheet if necessary): N es what section #No�� Was a System Problem Identified? Yes �,_.. Y This report on the existing onsite sewage system is valid for the permitted or historic (if Installed prior to permit requirements) use of the system only and does not constitute assurance of future Ca rO!Ii�dVspre is ° =a� that fimea�� permits) on this parcel. Any future application will be judged separately by the rules and � in I certify that the inform ' n provided is based on a review of County records and my direct observations at the time of Inspection. _ Name/SigrIature Date No guarantee of future onsite sewage system performance is implied or granted based on the information contained in this report. This report constitutes a summary of findings only. Permit # or Parcel # page 4 of b Evaluation of an Existing Onsite Sewage SS' rstem 07 /30 /04—pdf 1 . f` Jefferson County Department of Community Development 621 Sheridan St., Port Townsend WA 98368 (360) 379 -4450 Evaluation of an Existing Onsite Sewage System (EES) Draw on the back of this sheet a current plot plan showing location of:_, Buildings, Drainfields, Septic Tanks, Wells, etc OR attach a current p�n identifying these items. ALL SPACES MUST BE FILLED IN. w y I Pte_' i If information is not available enter (NV) or not applicable (NA). � �r+ � APR 2 4 203 Type of Evaluation X Evaluation of on -site sewage system ❑ Evaluation of drinking water ❑ Evaluation of on -site sewage & drinking water �'- i "i� ;!JIJNTY Reason,f�gT,- Evaiiration M -F'd LC�F�a1Ei.'_e Routine Operation and' Monitcring Inspection Real Estate transaction Complete a Permit # Building Permit Review and/or no septic permit on file Other, explain Tax Parcel #-L _2XSS_098_ Permitted System ,dyes no Permit/case # SEP`], -.-7 Subdivision, Division, Block and Lot(s) —b.3A Lot Size Acre or Dimensions X Current Owner A %'k „401. 0 *m Site Address %,,% Owner Phone # 3 (�0�30�. -'3�t3 Previous property owner name(s) - (NN if not known) !—�A Directions to Site JPnft <kR lo Vt. I#J Date System Installed ^-1 Awe of Dwelling 4- 13e&eems_ offs House Occupied ves Po, vacant how long? Who installed system? \tAARSai Send completed report to: Owner b iling Address Phon emaii/fax o -» .. Reaitor or Other Representative Name._ Df. .M �-RC [A,2. CABAL C�•w .01,�� Mailing Add hon /ema Evaluation of an Existing Onsite Sewage System Date of Inspection nIr` A123 Inspected by Water Supply (fill in only if water supply is being tested in this evaluation) Sample was taken Yes No Sample Results ° r : f w Well casing 12" above ground Yes No y ,,� r- i Sanitary Seal in place Yes No a I Public: offsite onsite Name of System ► APR 2 4 r Individual: offsite onsite Is well more than 100' to drainfeldldis osal component —Y es n jf gy , ot;j,Olstanp er ._.. Is well more than 50' to tanks and effluent transport line _yes_Iff6 jf !nof" s agce ONSITE SEWAGE SYSTEM // # Bedrooms /gallons per day indicated in County Health Dept. records for this case tp I:S #1 - Septic Tank Tank size gal. single compartment two compartment L° a N� [t E:T� material Riser to grade on inlet yes no. Riser to grade on outlet Yes 'k. no Condition of tank good needs repair, describe 1st comp. Scum (top layer) Q in. sludge (bottom layer)_ in. 2nd comp. scum in. sludge in. Was ground water observed leaking into tank ? yes X no If yes, where was water Condition of baffles: Inlet: _ repair material _ Outlet: oo _ needs repair material ( ,co cn rete) Screened Outlet >_no _yes, condition clean clogged/dirty Septic tank needs to be pumped (per Jefferson County code 8.15.150 (1) (b))___-:yes >& no Effluent level at outlet (mark level on circle) If effluent is below the outlet, indicate when tank was last pumped: ( eg: ) Does system include a. pump? yes If yes, complete the next section X no (if no skip to section 3) #2 - Pump Chamber Tank size gal. Material. Riser to grade? yes no Condition of tank good needs repair, describe Solids in Tank (see S. 15.150) yes no scurn in. sludge in. Was Ground water observed leaking into tank ? yes no If yes, where was water observed? Screen around pump? yes no Shroud around pump? Yes no Electrical Components j Pump operating Yes no, describe High water alarm functions Yes no, if no, describe Elec. Panel condition good needs repair, describe Pump cycle drawdown inches. Time for pump cycle minisec. Timer Settings minisec on min /hrs off Floats secured: yes _lc Permit # or Parcel # Documentl -1 of 4 Evaluation .of an Existing Onsite Sewage System #3 — Drainfeld Appropriate Vegetation in area _ X es no. Descn�be vegetation &AA%3�� Indications of surfacing sewage (check one) yes , if yes, describe and diagram on plot Ian no drainfield area is overgrown and not observable Signs of parking /driving in area yes no drainfield area unknown Ground settling or erosion Yes no overgrown /not observable Monitoring Port Observations (if present): Residual Head ves, # of inches no Ponding in trench Yes, # of inches of ponded effluent no Repair area is? Available as shown on permit _None evaluated or shown on permit Addendum is attached for evaluation of Treatment Unit or detailed evaluation of drainfield _yes_ c no COMMENTS (attach additional sheet if necessary): i p I I APR ? d. 2003 Vv_ •— ��E a4�(�i>aA�. �R� ��t��R -�„P -�—wo •5,�,�ae�, �� O'1'fi R pw►.�t"R. SA ID ONE %S j11P J Aafl A �j"a.�1F.• �'�+�s wo�u.a � �� AL+oa FRoM,'ii� o'�:G�NAL i���, �E G -t���o AR�a w��>� I�n�►,�s',�� - $,�ic'TA�,,�. UHF OF SEE ATTACHED ADDENDUM MtkcQ Was a System Problem Identified? Yes if yes, what section #. No This report on the existing onsite sewage system is valid Jor the permitted or historic (if installed prior to permit requirements) use of the system only and does not constitute assurance of future County approvals (such as building permits) on this parcel. Any future application will be judged separately by the rules and laws in effect at that time. 1 certify that the information provided is based on a review of County records and my direct observations at the time of inspection. ©lo ame /Signature Date No guarantee of future onsite sewage system performance is implied or granted based on the information contained in this report This report constitutes a summary of findings only. Permit # or Parcel # Documend 4 cf A Include the following items on your plot plan: ❑ Property boundaries ❑ Wells ❑ Names of adjacent streets ❑ Septic tank ❑ Driveways and parking spaces ❑ Drainneld (enter NN if unknown) ❑ Surface water (ponds,creeks, etc) ❑ North Arrow ❑ Buildings(residence, sheds, garages, etc) PLOT PLAN oygr y U ' 1 T 1 I� Permit # or Parcei # 455;E9 ...�...,e.,,, 2 of 4 1 M 00-1 APR 2 4 2003 ,� ! itFFFr � M GUJtj Y �' Y Cdr v ENVIROv CRf CK L L C. 1612 Hastings Ave. W. Port Tcwnsena. WA NEW, PH 360 - 379 -9�W0 s . ADDENDUM Enviro Check, L.L.C. Company Disclaimer DATE a 21 a?1 ADDRES 6dT3- OWNER�,,-rl,,x �is1..w1G 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, L.L.C. 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 or owner. Enviro Check, L.L.C. disclaims any warranty, either expressed or implied, arising from the inspection/evaluation 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,L.L.C. does not make any claim, warranty or guarantee as to where property linesiboundaries of properties are located. And does not warrant or guarantee any encroachments from on site sewage systems on to adjacent properties. Any indications of possible property lines/bound anes?rpprx' and do not indicate legal property lines or boundaries. Company Enviro Check, L.L.C. APO 2 4 2003 1612 Hastings Ave. W + _ Port Townsend, Wa. 98368 � � _ 360- 379 -9400 ZFFERSON COUNTY (E, OF rIJEVI IY OC.4'ELOFEa�GtJT knowl___: a that I have studied the information contained herein and that my assessment is honest, done accordance with J— eI e Ordinances, and to the best of my ability, correct. Da R. Wurtsmith Co- Manager Weather Conditions SAMPLING (Septic tank) MEASUREMENTS Date - PH Result DO Result - Temp. Result- Counter Settine- Hour Meter - Water Usase (Ave.GPD) Meter - Squirt Hei&ht (In feet)- OLYMPIC HEALTH DISTRICT AS court HOW% Townsen7 Fashington 98368 + ° Caroline 0IMeIC HEALTH DISTRICT P ermit �o. � C� Ang Fee Paid SEWAGE DISPOSAL PERMIT APPLICATION - Submit in Duplicate 13 j ("j ..._....��.r.�. --- Cff /°fir ADDRESS 34u 2 � 2- DATE LC OE�%L � �r.rn� err rrrn %m' 3 7 G .L DESCRIPTION - P$ONE .DIRECTIONS FOR LOCATING SITE deaz e /l Aw -i1 A f if /0;/j /d D �D .. - -- APPLICATION IS HEREBY MADE TO:F INSTALL NEW SYSTEM REPAIR EXIST =G SYSTEM,• E 0F EpUILDING N0. OF BEDROOMS BASEMENT SITE S -TZE AME: OF INSTALLS 10 -Property lines r--'° 7. Driveways, patios, carport!' etc. 2. Location of building tf 8®, Streams or bodies of water nea y' -� �_� Location of septic tank✓ g. Location of perco tion test a °ol .*_Location of ` flrainfield ✓ _ 10. Septic tank size E -Slope of land 11. Length of proposed drainfield ,,.--.Water lines & well(if applicable)&/ 12. Depth to water if encountered. Depth of hole Pere. No. 1 Pere. No. 2 (� Pero. No. 3. i PERCOLATION TEST RESULTS required to Percolation rate type p1 °v.%` last 6 in. (divide time by A DBAINFZELD LENGTH WIDTH DEPTHS N ©. OF LINES,,.,,. IRVB REED THAT THE PROPOSED INSTALLATION WILL BEL MADE IN Tffir MANNER AS- DESIGNED AND APPROVED ON THIS AIPPLICATION. /k •APPROX, DATV' OF INSTALLATION . �ilr�llirlr r•. I�r•�� SANITARIAN IS COMMENTS: TSI�C:C�1V ;TI2 ERMIT WHE PLAN = APPRL�i,'E5� DnR T14�F.C91TP, i� / -7 REMARKS: I CERTIFY THL.T DEPARTMENT. DISAPPROVED Sinature of pplicant 4 0 f7, Z IN THE KANNER APPROVED BY T IE D..TE 9 dhi III, 14 Iii Jefferson County Department of Community Development 621 Sheridan St., Port Townsend WA 98368 (360) 379-4450 �LRF 117 4 MONITORING INSPECTION CERTIFICATION �ip The system serving L� '`"C-- " 1 � on parcel # 602 ? nar— , permit # `% 2 — 7E- was most recently inspected on �i� �0 3 by � (A , as specified in Jefferson County Code 8.15.150. The above referenced system is in compliance with the Monitoringlinspection schedule Identified in Table 1 of Jefferson County Code 8.15. itSee report completed. q(2� (° 3 for Information on the condition of the onsite sewage system. ❑REQUIRED 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 20( Table 1 requires that this system receive an inspection: Annually Every 3 years Every 6 years LJ 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 Employee H: emv_ health \linda \GD \FORMS\MONITORING INSPECTION CERTIFICATION.doc � 1, 163 Date