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Home My WebLink AboutSEP1974-00178%.vunry uepan,ment or community Development 621 Sheridan St., Port Townsend WA 98368 (360) 379-4450 '` - Evaluation of an Existing Onsite Sewage System (EES) Office Use Only Date Fee - R Draw on the back of this sheet a current plot plan showing location of: Check Buildings, Drainfields, Septic Tanks, Wells, etc OR attach a current plot plan identifying these items. h c -- ALL SPACES MUST BE FILLED IN. ®__ If information Is; not available enter (NV) or not applicable (NA). o t p MAR 1 2 2004 _� Type of Evaluation Reason fo� Evaluation, e O outine Operation and Moni it pectior, �vE. ':'jt Evaluation of on-site sewage system Lif eal Estate transaction 0 Evaluation of drinking water 0 Evaluation of on-site sewage & drinking water O Complete a Permit # 0 Building Permit Review and/or no septic permit on file 0 Other, explain Tax Parcel # � F5/ FOO Od / Permitted System /_ es no Permit/case # SEP % // 1r --'?l Subdivision, Division, Block and Lot(s) '_ C / 1 %-11 -1 i TiD�S Lot Size Acres or Dimensions 1-2 r;' X CG' �- Current Owner -)A wi F5 Fdo m �sr ✓� Site Address �l�_��HC-POP60P 0.17 %)R 11" Owner Phone #-3-1`3 - 70 q- 6 6 1 3 Previous property owner name(s) - (NN if not kn Directions to Site- V y /61 Tai' 1 -Ac -)4 ,D114t1,r -1p T -c -l� 14cige pewol?rjotyl G?C'RTl l I Gy L y I � I L I= 1 Date System Installed_ / y 7 !1 Age of Dwelling / 11--1 # Bedrooms-)—,- House edroomsHouse Occupied ----_yes no, vacant how long? Who installed system?_ M C IIA k D SO 0 Send completed report to: Owner Name_ Jai 01 C-7-5 T 1-IcV) I P 5 oo Mailing Address155_2 7 5E 1 A q %'I-) 19V,�F %'rlm-Av?o d/� y7 2 33 Phone/email/fax 50 3 -70 y -6613 Realtor or Other Representative Name_ ,R A 0) Y CA L K) o North Sound Septic Serr:ce 601 Werner Rd. Mailing Address Port Ludlow, WA 98365 Phone%maiUfax include the following items on your pi9t pian: roperty boundaries O 0 % 1 C91 FJ E P o- ells PGy f3 J C Vames of adjacent streets r�' S:ra tic tank tD� riveways and parking spaces Dnfield (enter NN if unknown) �urface water (ponds,creeks, etc) North Arrow r J£P Buildings(residence, sheds, garages, etc) A/ � Permit # or Parcel 2 of 4 vusuauut, ur an cxisUng onsite Sewage §Ystem Date of Inspection �f U Inspected by - e - ----� . �•. Water Sup DIV : (fill in only if water supply'is being tested in this evalu 'on) Sample was taken Yes No Sample Results Well casing 12" above ground Yes No �A� 200 Sanitary Seal in place Yes No �� Public: offsite onsite Name of System i Individual: _ offsite onsite _PT. OF cY , -TtT-o 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 # Bedroomstgallons per day indicated in County Health. Dept records for this case #1 - Septic Tank Tank size -a-- gal, single compartment two compartment e C�1 cI;,TC material Riser to grade on inlet Riser to grade on outlet yes o Condition of tank cood needs repair, describe 1st comp. Scum (top layer �_in. sludge (bottom layer) _ in, 2nd comp. scum in. sludge f][_A in. Was ground water observed leaking into tank ? ves (no) If yes, where was water observed? Condition of baffles: Inlet: ood needs repair material (PV Concrete Outle ood needs repair material (PVC on e. Screen utlet 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: ( e9: )CL Does system include a pump? yes If yes, complete the next section no r no skip to section 3) #2 - PumD Chambergood Tank size gal. Material. Riser to grade? ves no Condition of tank needs repair, describe Solids in Tank (see 8.15.150) —yes no scum in. sludge in. Was Ground water observed leaking into tank ? yes no If yes, where was water observed? Screen around pump?______,ves no Shroud around pump? yes no Electrical Components 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 _ min/sec. Timer Settings —min/sec on min/hrs off Floats secured:_ ves no Permit # or Parcel # 541P 71-1 f 7 8" D=ur&Ml 3 of 4 Evaluation of an Existing Onsite Sewage System #3 — Drainfield G S S Appropriate Vegetation in area es no. Describe vegetation Indications of surfacing sewage (check o ve3,, if yes, describe and diagram on plot plan drainfield area is overgrown and not observable Signs of parking/driving in area vesno drainfield area unknown Ground settling or erosion es no overgrown/not observable Monitoring Port Observations (if present): ^ r Residual Head yes, / VIA- # of inches no Ponding in trench yes, # of inch 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 Ono COMMENTS (attach additional sheet if necessary): V fl occ 1"I A5sL % ay 1-'9 r, a r 'toe 55ie L' 5 EC D �i MAR 12 2004 LEPT.OF Was a System Problem Identified? Yes if yes, what section #. No 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 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. I certify that the information provided is based on a review of County records and rpy dir9ct observations at the time of inspection. A0 Name/SigWature 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 # L- -71- 4701 -- oocuffmm 4 of 4 '' 903 E. Caroline Port Angeles Court House OLYMPIC HEALTH DISTRICT SEWAGE DISPOSAL PERMIT APPLICATION Submit in Duplicate Permit No,y� Builder Z —r- e Port Townsend Date � � ��Y OWil RESS_ PHONE DIRECTIONS FOR LOCATING SITE IS,. H Y MADE TO: INSTALL N34 SYSTEM PAIR EXISTING SYSTEM �7ING N0. OF BEDROOMS BASEPIENT SITE SIZANAME OF INSTALLER DRAINFIELD LENGTH I,11IDTH �� a DEPTH 2Y" #LINES a SEPTI ¢ TANK SIZE ®� DRAW A DETAILED PLOT PLAN BELOW. SEE INSTRUCTIONS. SOIL .TYPE ... +.r.w..a.+.gray 't u I►iI ivvn�.ivty _wit uiiiq a,avr.ra.u.�,✓ni•^= a.ai•• PERMIT UNLESS PRIOR APPROVAL OBTAINED FROM THE UALTH DEPARTMENT, TE OF INSTALLATION SIGNATURE OF APPLICANT A ROVED DATE INSPECTED BY DATE y SANITARIA,.N'S COTTUTTS: �fa��ZY _ ��`� �,• � p o� I CERTIFY THAT THiSTST LED ° N THE MANNER APPROVED BY THE HEALTH DEAPRTMENT - DATE S RS NAME • 303 E. Caroline Port Angeles Court House Port Townsend OLYMPIC HEALTH DISTRICT SMIAGE DISPOSAL PERMIT APPLICATION S'u'bmit in Duplicate DIRECTIONS FOR LOCATING SITE . t Permit Now Builder ate `S' 3 9 PHONE APPLICATION IS HEREBY MADE T0: INSTALL N7E 4 SYSTEM REPAIR EXISTING SYSTEM YPE OF BUILDINTG A �LLER NO. OF; BEDROOVS BASEMENT SITE SIZ Pct OF �r DRAINF ELD LENGTH �JIDTH DEPTH P4X7A INESSEPTIC TANK SIZE DRAUl _k DETAILED PLOT PLAN BELOW. SEE INSTRUCTIONS. SOIL TYPE ANY,CHANGE IN BUILDING OR SE' -AGE DISPOSAL PLANS, LOCATION OR SITE, INVALIDATES THIS PERMIT UNLESS PRIOR APPROVAL OBTAINED FROM THE HLALTH DEPARTMENT. DATE OF INSTALLATION SIGNATURE OF APPLICANT-;&�., APPROVED DATE INSPECTED BY DATE SANITARIAN'S CO11MaTS: I CERTIFY THAT THIS SYSTEM ':IAS ]ITSTALLED IN THE MANNER APPROVED BY THE HEALTH DEAPRTMEW D INSTALLERS NAME