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HomeMy WebLinkAboutSEP1969-00005Jefferson 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, Drainflelds, Septic Tanks, Wells, etc OR attach a current plot plan Identifying these Items. ALL SPACES MUST BE FILLED IN. . If information is not available enter (NV) or not applicable (NA). Office Use Only Date l ' Fee G Recpt ' 0 Check case # -J Type of Evaluation Reason for Evaluation ❑ Routine Operation and Monitoring Inspection 5t Evaluation of on-site sewage system 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 & drinking water ❑ Other, explain Date of evaluation � n 21� j:fl Inspected by 011111111 W11(En*odWCk, LLC) Tax Parcel # An .o 4g=;4.64, Permitted System ,dyes no Permit/case # SEP 4°I -5 Subdivision, Division, Block and Lot(s) P&O -r- +j. L.0 -r- too Lot Size '� �� cr or Dimensions X Current Owner .S yam.% Slie Address_,, Owner Phone Previous property owner name(s) - (N/V if not known) x.24, Directions to Site F#., rr. r,_ :s t k3 �6" � ��„T�gTt R V-%:- a- Ri�C3 Via_ AT, Date System Installed Age of Dwelling Vg -lo # Bedrooms_ House Occupied dyes no, vacant how long? Who Installed system?_ Send completed report to: Owner Name Mailing Address Phone/email/fax Realtor or Other Representative Namely g -L ► ti s.�, ' L.0 Mailing Address EES Evaluation FotTn 07-30-04_pdf page.1 of h aserfisbe WebLijik LaserfichW WebLink emww So" TaToatm Pamft Case mai WSued Date Rnaled Date First Name Last Name MLA DocunUtType bV://Iestco.jeftsoiLwiLm/wcblW=VDwViewmpOid=W4335... H 0 Logmt MyVMAh* 2325% ::*1 Pag*2 10:17._._ JEFFERSON:- Erakommrdd Hewh:-- Sepffcffier-mslb seagge cam z- Pdfic Fuss 1969 Pd*efts SEP69 > SEPS94M trd&W* the Wmi" ftwo an your pW plwc • pmp" um a vveft • Nm -m ofadjwem is W& • Downsp W4 pw4lg spews 6-0rdn ft w (~ M V ff w d m W) • alfim Vale Wwdwftks. M) a NmthAmw u f �^ - gwadw dA-&* aim N—PAP-77swoutot, [a OCT 2 6 L,001i PMM-W by Las"" M-"W=d Iona; W - Of 1 10/19/2009 4:37 PM Date of Inspection t n n!,d9 Inspected by Water Supply (fill in only if water supply is being tested in this evaluation) 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 drainfleid/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 # Bedrooms/gallons per day indicated in County Health Dept. records for this case #1 - Septic Tank Tank size . `192 1tl'" gal. ,single compartment two compartment ?,-,,ze.R. g f material Riser to grade on Inlet yes k no. Riser to grade on outlet yes k no Condition of tank X good needs repair, describe 1st comp. Scum (top layer) l' --in. sludge (bottom layer) in. 2nd comp. scum In. sludge in. Was ground water observed leaking into tank ? yes —)— no If yes, where was water observed? Condition of baffles: Inlet: ood needs repair materia PVC ncrete) Outlet: ood needs repair maters PV concrete) Screened Outlet _)g,_no __yes, condition clean clOgged/dirly Septic tank needs to be pumped (per Jefferson County code 8.15.150 (1) (b)) yes _X _no 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 section _ no (if no slip to section 3) ##2 - Pimp Chamber Tank size gal. Material. Riser to grade? yes 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 ? yes no If yes, where was water observed? Screen around pump? no yes, condition clean dirty/clogged Shroud around pump? no Yes 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: yes . no Permit # or Parcel # Evaluation of an 94sting Misite Sewage System _07/30iO4_P df page 3 Of 5 #3 Drainfleld Appropriate Vegetation in area _-yes no. Describe vegetation Indications of surfacing sewage (check one) __yes, if yes, describe and diagram on plot plan Y no drainfield area is overgrown and not observable Signs of parking/driving in area ves noX 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? _�►vailable as shown on permit _None evaluated or shown on permit Addendum (page 5) is attached for evaluation of Treatment Unit or detailed evaluation of drainfield __yes_�•no COMMENTS (attach additional sheet if necessary): other W No permit is on file as to size, location or adequacy and itcouidnot bedetermiisd. Cw4-0- A-10�%JtieN t psrie.a.Q�) ® Plow. -r Wh 6+ P -,r b^Lei. SEE ATTACHED ADDENDUM e r Was a System Problem Identified? Yes Y, N 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 my direct observations at the time of Inspection. ---�---� � � X309 Name/Signatu Date No guarantee of future onsite sewage system performance is implied or granted based on the intb7atign contained in this report. This report constitutes a summary of findings only. Permit # or Parcel # Evaluation of an F�dsting On Sewage §stem _0 7130/04_pdf page 4 of 5 # !09 -S'_ DATE rc�?3aS ADDENDUM ADDRESS ao �,►� �'.�p a -r:. L EnvL o Check, L.L.C. Company Disclaimer OWNER- Fcysl 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 fimctioning 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 fimction of a septic system. And the inability of our company to supervise or monitor the use of the system, gr to inspect none visible areas of the system, this report shall not be construed as a warranty by our company that the system will fimction properly for any particular owner or buyer. E$viro Check, L.L.C. disclaims any warranty, expressed or implied, arising from the inspection/evaluation of the septic system or this reportlevaluatiion. We are also not ascertaining the impact the system is having on the groundwater table or environment. Enviro Check,L.L.C. does not make any claim,, warranty or guarantee as to where property lines/boundaries 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/boundaries are approximations and do not indicate legal property lines or boundaries. Euviro Check, LLC EES reports do not state where the exact location of dminfields are located- Only the general area is indicated, based on permit information that may or may not be correct. Enviro Check, L.L.C. will not be held responsible in any way for information being undisclosed (intentionally or unintentionally) by Jefferson County employees, property owner, representative or other parties of interest. All reports, including E.E.S. inspection reports are subject to any change by Jefferson County Environmental Health Department. Enviro Check, LLC is not liable for any such changes. All parties are encourages to check county records for any information regarding properties. COMBanv Enviro Check, L.L.C. 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 Ance fferson Coun y Ordinances, and to the best of my ability, correct. R. Worts - er SAMPLING (Septic tank) PH Result - DO Result �MENTS Counter Setting- PC SF Hour Meter- PC SF Tenn. Result 0 C � _ Jefferson County Department of Community Development 621 Sheridan St., Port Townsend WA 98368 (360) 379-4450 Evaluation of an Existing Onsite Sewage S ystem (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 plot plan identifying these items. ALL SPACES MUST BE FILLED IN. If information is not available enter (NV) or not applicable (NA). Type of Evaluation 5Q Evaluation of on-site sewage system 1K ❑ Evaluation of drinking water ❑ ❑ Evaluation of on-site sewage & drinking water ❑ Office Use Only Dates 13 Fee Recptl 1 Lt Check-3013— Case # S Reason for Evaluation Routine Operation and Monitoring Inspection Real Estate transaction Complete a Permit # Building Permit Review and/or no septic permit on file Other, explain Date of evaluation 0-1 0(o©7 Inspected by Olga (EMOChed, LLQ Tax Parcel # q OL\on k-S(a Permitted System _yes )�_no Permit/case # SEP Subdivision, Division, Block and Lot(s) wl: I- DL.' -'!tee t Q 4 � .,T Lot Size ,STI' Acre or Dimensions X Current Owner uwa Site Address &Tt 1643 Owner Phone # ?�, (n - yr371--0 Previous property owner name(s) - (NN if not known) Directions to Site �i� ` �' � �� - ` E 18 'Sw q 11 i UE 211 Date System Installed Age of Dwelling b # Bedrooms_ House Occupied yes no, vacant how long? P(f Who installed system? Send completed report to:T Owner���, Name CM&Us di& L_ti .3pX 'OkLKER Mailing Address �d R&\, AeL cam', _ Po( s�©��►a `t�3 ho)a/email/fax 'Kto ^ 43'7^046� )' Realtor or Other Representative Name Mailing Address Phone/ema�1 2t,.o�t-k31-�.4tf i� 5e 6(ooi $.r F-u�bRoCl�t EES Evaluation 1= an i_ 07-30-O4_pdf page 1 of 5 Include the following items on your plot plan: ❑ Property boundaries ❑ Names of adjacent streets ❑ Driveways and parking spaces ❑ Surface water (ponds,creeks, etc) ❑ Buildings(residence, sheds, garages, etc) PLOT PLAN -date prepared n:] d (o b^7 OF ❑ Wells ❑ Se tic tank Drainfield (enter NN if unknown) ❑ North Arrow —7a � et -c sip E F w �c \NOT TO SCA Permit # or Parcel #—:�iE Evaluation of an Existing LLC - 1612 Hastings Ave. W. Port Townsend, WA 98368 Sewage S ystern _07/30/04_idt page 2 of 5 Date of Inspection C j pG©—] Inspected by Water Supply (fill in only if water supply is being tested in this evaluation) 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 `{ # Bedrooms/gallons per day indicated in County Health Dept. records for this case V #1 - Septic Tank Tank size � ��#I-:- al. �c single compartment two compartment egg - (C- material Riser to grade on inlet / ves_ no. Riser to grade on outlet ______yes__>o no Condition of tank 5c good needs repair, describe 1st comp. Scum (top layer) in. sludge (bottom layer) "F" in. 2nd comp. scum in. sludge in. T Was ground water observed leaking into tank ? ves_ no If yes, where was water observed? Condition of baffles: Inlet: needs repair materialV ,Concrete) Outlet: o needs repair mated (P ,concrete) Screened Outlet IK des, condition clean dogged/dirty Septic tank needs to be pumped (per Jefferson County code 8.15.150 (1) (b)) yes ono 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 section �_ no (if no skip to section 3) #2 - Pump Chamber Tank size gal. Material. Riser to grade? ves no Condition of tank 000d 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? no ves, condition clean dirty/clogged Shroud.around pump? no ves Electrical Components Pump operating -eq - 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: yes no Permit # or Parcel # 15_ tog --s- Evaluation 'SEvaluation of an Existing Onsite Sewage System _07/30/04},agP 3 of ..; #3 — Drainfield Appropriate Vegetation in area ves no. Describe vegetation_ J Indications of surfacing sewage (check one) yes, if yes, describe and diagram on plot plan no drainfield area is overgrown and not observable Signs of parking/driving in area ves no X 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 )o _None evaluated or shown on permit Addendum (page 5) is attached for evaluation of Treatment Unit or detailed evaluation of drainfield _yes__)_'__no COMMENTS (attach additional sheet if necessary): -#- k -- A . V% sF-K AW ti ova IN I�� dR� . other (ag) No permit is on file as to size, location or adequacy and it Could not be determined SEE ATTACHED ADDENDUM jr-WI-Pp" 114111 I'D JUL 1 3,2:j7 Was a System Problem Identified? Yes --fX, if yes, what section #. M 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 th information provided is based on a review of County records and my direct observations at the time of inspection. Name/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 # Evaluation of an Existing tisite Sewage System _07/30/04_pdf page 4 of 5 DATE c,-7 -co o" 7 ADDENDUM ADDRESS,JU..'- Enviro Check, "c. Company Disclaimer OWNER Ui„ . fit., 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 fimctioning 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 function of a septic system. And the inability of our company to supervise or monitor the use of the system, or to inspect none visible areas of the system, this report shall not be construed as a warranty by our company that the system will fimetion properly for any particular owner or buyer. Enviro Check, L.L.C. disclaims any warranty, expressed or implied, arising from the inspection/evaluation of the septic system or this report/evaluation. Weare also not ascertaining the impact the system is having on the groundwater table or environment. Enviro Check,L.L.C, does not make any claim, warranty or guarantee as to where property lines/boundaries of properties are located. And doss not warrant or guarantee any encroachments from on site sewage systems on to adjacent properties. Any indications of possible propeay lines/boundaries are approximations and do not indicate legal property limes or boundaries. Enviro Check, LLC EES reports do not state where the exact location of dcainfields are located. Only the general area is indicated, based on permit information that may or may not be correct. Enviro Check, L.L.C. will not be held responsible in any way for information being undisclosed (intentionally or unintentionally) by property owner, representative or other parties of interest. All reports, including E.E.S. inspection reports are subject to any change by Jefferson County Environmental Health Dent. Enviro Check, LLC is not liable for any such changes. All parties are encourages to check county records for any information regarding properties. Comnv Envire Check, L.L.C. 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 4C=:7on County Ordinances, and to the best of my abiy,orrect. Co -Manager r SAMPLING (Septic tank) PH Result - DO Result Tema. Result MEASUREMENTS Counter Setting PC SF Hour Meter- PC SF 903 East Caroline QLMR r L T Z'*E in♦ - zo 1ms"MON IS BEMY SDE TO: INST" =9 d Permit N" LjnL .Yee Paid , ;�Fm ON THE ..SIDE,, 1M0 .0 MMA?i n YWT PLAN GIS M FoJ.i. 7MZ _MOMUTIQN: 1. Property lines 7. DrivewaYse, Batiost rarPcr is etc., 2. Lo ation. of building 8, Streams or bodies of water nearby —J. -Location of septic tank 9. Location of percolation test holes 4• Location of drainfield 10, septic tank sire ' allonst 5. Slope -of land " Langth- of proposed drainfield 6. Mater lines and well(xf -appl ceble) " Depth to water if enomutered PERCQLLTION TEST PJWULTS Depth Time required to Percolation rate 0 hole seep last 6 inches (divide time by 6) Peres No. L Bert: No, 2 Peri;. No. 3 DRAnUTM LEWGM Wim We of Soil � __•_ +0 UILL BE MM. r' MAMM AS Signaturqjb RETAPIANtS, M+11;.i1W 1.. ♦ 41 Y� ' _'_fir °a rD, !- �x ♦?_ 91C '� 1 • : ► .. y♦ t 7P1 , SXETCH PS,AN ON �50RID BELOW q : SC T BETWEEN 10 EN LI N ES ''INDICATE NORTH I I I ,.:I, ov p I I I I i SII' I I f —. I I �I 4. II I' II I iI .. i l JJ I, ' I ! IiI!' .a a .I 1 i i I I I tlr , Iii I I C� 1 I �I f IG II - i i' 0 .. Q I SII I r N I is 1 I I' ' I LJ I 5 P 6r on -7r' ount th Department °° '� 'j Receipt No. �l� `fi,/ t X02 s+rgridan Ave. = // . Porgy Townsend, WA 98368 �%� FFB 1 `!wee: (pd • d' 206-385-0722 199 • Date: /3 lT k-1.�3.,� EVALUATION OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM AND �OR��4� SUPPLY Information Remieated: �Indiui aal SeFrage Disposal S;,st?m _. Water St_I ply private Applic:an..t_s Namevile PA 14a , t T ! i p� ^�tai.� C.nmpletFrl Resor.. ..o: CUners Name f Adm' _�._,$ i Phone: a iG Previcn_Is comer (if Known) Legal Description- Seco Street Address G & !ti SIIOGE DISPOSAL Permitted system yes no Installed prior to permit rw-,jurement yes X no Sere noted on grcnand at time of inspection* no HcniGe is unoccupied therefore an evaluation of drainfield performanr_.e is not possible at this time. A review of m -w records indi.c-a-te that this syste-mwas designed to service a bedroc_m► residence. This systFm is not cxmsidered aci-q ate for a bedroom residence :m] it is sized per current reVa.lations. Septic tank should be p.anped if not done within past_ e - 5 years. WATER Y b Well easing 12" above grenand yes no Sanitary seal in place ;res no Well 100' from drainfield yes _no Water sample taken yes nn- Sample nSample results Ckxnmts: -BaWa CSLA Date Ernrironment_al health ._Specialist * This report. sloes not nonstitlzte a gizarantPe, either written or implied, that the system will continue to f7.Inc:tlon properly. This report C Stitutes a my ary of findings only. EESFORM 11/88 N 109 e GCI,'D'AAM SE?TIC DISPOSAL P.O. Box 233 PORT TOWNSEND, WA 08363 (206) 385-2557 f- i -. . CUSTOMER'S ORDER NO. PHON � DATE 19 NAME ADDRESS pN A RETD r�oaT7777777 M :41 -Z- _.._. 7.- I 4-44 _..r v;..........._. _. TAX 80LD SY RECEIVED Sr TOTAL <71,f7, All claims and returned goods MUST be +� 6 q accompanied by this bill. �"YOu 1 4� PROM 6014�. Ia. kta VM 01471. COMMUNIC PUBLIC HEALTH VITAL DISEASE CONTROL NURSING STATISTICS ENVIRONMENTAL HEALTH HEALTH EDUCATION JEFFERSON CCS UNT Y HEAL TH DEPAR TMENT 802 SHERIDAN PORT TOWNSEND. WASH. 98368 LYLE PHILLIPS C/O BART PHILLIPS 1105 TAYLOR PORT TOWNSEND WA 98368 RE: Building Permit, 66 Rainier Ct. Dear Mr. Phillips: (206) 385.0722 February 10, 1992 On February 3, 1991 the Jefferson County Health Department received a building permit for review. In order to complete our review and give approval for the Building Permit our office must complete an evaluation of the existing system to determine the systems adequacy and that it is functioning properly. An application for the evaluation is enclosed and the instructions are on the back. Please return the application and sixty dollar fee with an accurate plot plan. Please contact our office at 385-0722 if you have further questions. Sincerely Linda Atkins Environmental Health Specialist enclosure FEB 4 1992 Y F �! JEFFERSON C0Urq!r"-Z BUT LDZ NG ADPL= CAT= ON Jefferson County Planning and Building Department Courthouse, 3rd Floor PO Box 1220 Port Townsend, WA 98368 206-385-9141 :RMIT #....:BLD92-0054 DATE RECEIVED.:01/30/92 ;'TE ADDRESS:66 RAINIER CT :PORT LUDLOW, WA 98365 ----------------------------------------------------------- qNER ....... LYLE PHILLIPS PHONE: 385-6767 `-XILING ADDR:C/O BART PHILLIPS :1105 TAYLOR :PORT TOWNSEND WA 98368 -------------------------------------------------- .)NTRACTOR..:NO CONTRACTOR PHONE: NILING ADDR: :)NTR. LIC #: EXPIRATION DATE: ------------------------------------------------ RCHITECT/..: PHONE: e ESIGNER....: AILING ADDR: g� --- ----- ------------------------------------------- -1EALT - -- - ARCEL NO ... :990400-456 _ EGAL DESC..:STR 16-28-01 EWM, TAX # DATE: icy OT 60 , BLOCK , PL #1, AREA 4 =LINES: By; DATE: DESCRIPTION OF IMPROVEMENT: remodle kitchen, bath, bedroom, roof -------------------------------------------------------- UILDING TYPE ...... :RES BEDROOMS--- BATHROOMS-- MAIN FL...: 0 sf 'YPE OF IMPROVEMENT:ALT EXIST.: 3 EXIST.: 1 2ND FL....: 0 sf ARAGE/CARPORT ..... : PROP..: 0 PROP..: 1 3RD FL....: 0 sf 1OODSTOVE.......... : TOTAL.: 3 TOTAL.: 2 BASEMENT..: O sf fBC OCCUPANCY GROUP: SEWAGE DISP..:SEPTIC CARPORT...: 0 sf 'YPE OF CONST......: WATER SUPPLY.:PRIVATE GARAGE....: 0 sf 'NITS.: 0 STORIES:O HEAT TYPES.: DECKS.....: 0 sf -IMENSIONS:-------MOBILE HOME----- COMMERCIAL: 0 sf 'RAME TYPE: MAKE: YR: INDUSTRIAL: 0 sf ;ST COST.$: 20000 SIZE: BANK HT... :0 ft 'ROJ GRP..: 2508 SH SETBACK:O ft -------------------- ------------------------------------------ )wner/agent ---------------- ;; rTnntvre - type amount )ate: ssued By: PRMT $ 207.00 PLCK $ 31.05 B.C. $ 4.50 FEES -------------- by date recpt MM 01/30/92 61930 MM 01/30/92 61930 MM 01/30/92 61930 )ate: __ `___—___. ___ ___---_- _ -----_------------------ ----------------- lC��� 242.55 TOTAL ,►-J �`l 9 Port An eles Yee Paid r g (r..... f SEfRAGE DISPOSAL PMUT AYP1,ICATIO14 Wbmit in Duplicate -NAME :' �� l iy ) ' 241 120 Lam' DATE �- 4 9. LWIAI. DESCRIPTION 1.4 r DIIECTI ONS FOR LOCATING SITE�i.� APPLICATION IS H&MY MOE TO INSTAIL IM SYSTEM✓��� STING SYSTFA - _-- 0 O BU11DING I NO. OF B.EDR BASEVIENT SITE SIZE NAME OF INSTALLER ON THE REVERSE SIDE.. DRA17 A n}Y!'A UD PLOT PLAN GIVING THE FOLLOWING INFORMATION: 1. Property lines 7. Driveways., patios, carport. etc.. 2* location of building 8. Streams or bodies of Prater nearby ------ 3- -Location of septic tank 9. Location of percolation test holes 4* Location of drainfield 10. Septic tank size r al1-ons 5. slope -of land. 11. Length of proposed darainfield 6. Water lines and well(i:e applicable) 12. Depth to Prater if encountered Depth of hole Perc. No. 1, Pere. No. 2 ' Pere. No. 3 Time required to seep last 6 inches Percolation rate (divide time by 6) Type of Soil ! �/Gr� c� '�` r► . - 1 IT IS HZIMY AGREED THAT THE PROPOSED INSTALLATION DILL BE MOE IN WE Di&Z= AS DESIGNED AMID APPROVED ON ZIIS .APPLICATION. �_ Signatur�f pplicant AP.PROX. DATE OF IM�iTAT.I.AT'I C1MT zL / 6 -- � r � �,y SnNTZaR7ANtS (�S= 01IS CONSTITTJTES A PF.il1l+1IT HF;ALTH O 11 CER t S SIGNATURE APPEARS AS APPRO PLAN APPROVED �iir-r'' - J DISAPPROVED -- DATE--- �'_ — 'Ji r JEFFERSON COUNTY BUILDING APPLICATION Jefferson County Permit Center Castle Hill Mall 621 Sheridan St. Port Townsend, WA 98368 206-379-4450 PERMIT #....:BLD93-0514 DATE RECEIVED.:07/21/93 SITE ADDRESS:20 RAINIER CT :PORT LUDLOW, WA 98365 --------------------------- _.7-�------------------------------------------------- OWNER ....... :LYLE PHILLIPS PHONE: MAILING ADDR:20 RAINIER CT :PORT LUDLOW WA 98365 ------------------------------------------------------------------------------- CONTRACTOR..:H & M CONSTRUCTION PHONE:437-2740 MAILING ADDR:311 MATS VIEW DR :PORT LUDLOW WA 98365 CONTR. LIC #:HMCON**291M2 EXPIRATION DATE: --------------- ARCHITECT/...PHONE: DESIGNER....: MAILING ADDR: ------------------------------------------------------------------------------- PARCEL NO ... :990400456 SEPTIC: D)X DATE: LEGAL DESC..:STR 16-28-01 EWM, TAX # WATER : DATE: LOT 60 , BLOCK PL #1, AREA 4 SHOR BY: DATE: DESCRIPTION OF IMPROVEMENT: garage ------------------------------------------------------------------------------- BUILDING TYPE ...... :GAR BEDROOMS--- BATHROOMS-- MAIN FL...: 0 sf TYPE OF IMPROVEMENT:NEW GARAGE/CARPORT.....: EXIST.: 0 EXIST.: 0 PROP..: 0,,--fROP..: 0 rHTED ADD'L FL..: BSMT.: 0 sf 0 sf WOODSTOVE.......... : TOTAL.: 0" TOTAL.: 0 UNHT BSMT.: 0 sf UBC OCCUPANCY GROUP: SEWAGE DISP..:SEPTIC CARPORT...: 0 sf TYPE OF CONST......: WATER SUPPLY.: GARAGE....: 264 sf UNITS.: 0 STORIES:O HEAT TYPES.: DECKS.....: 0 sf DIMENSIONS: -------MOBILE HOME------ COMMERCIAL: 0 sf FRAME TYPE:WOOD MAKE: YR: INDUSTRIAL: 0 sf EST COST.$: 2640 SIZE: BANK HT... :0 ft PROJ GRP..: 2508 SH SETBACK:O ft -------------------------------I----------------------------------------------- Owner/agent ---------------- FEES -------------- Signature: type amount by date recpt PRMT $ 54.00 AK 07/21/93 81215 Date: PLCK $ 16.20 AK 07/21/93 81215 B.C. $ 4.50 AK 07/21/93 81215 Issued By: Date: $ 74.70 TOTAL 7/2--7- PLOT PLAN INDICATE the following information. Draw to scale. Use 1 square to equal no more than ten (10) feet. ❑ 1. North arrow 0" 2. Property boundaries and dimensions 3. Names of adjacent streets 9"" 4. Driveway/s &O"S. Major features such as ravines, seasonal creeks, bodies of water, etc. ❑ 6. Septic tank and drainfield location, existing or proposed, and distance to r _ closest structure J] 7. Sewer lines ❑ S. Wells and/or water lines ❑ 9. Neighboring wells within 150 feet ❑ 10. Paved surfaces (patios) ❑ 11. Structures, existing or proposed, _ together with setbacks (distances to property boundaries) ❑ 12. Easements for access or utilities ❑ 13. Arrows showing direction of slope -- assume an elevation of 100 feet at one lot corner and indicate the other lot corner elevations in relation to it. For applications adjoining shorelines, INDICATE: ❑ 14. Ordinary high water mark ❑ 15. Top of bank, if over 10 feet high ❑ 16. Slope of bank in degrees r Indicate scale of plot plan: One inch equals _ (Grid is in 114 inch squares) c v PLOT PLAN INDICATE the following information. Draw to scale. Use 1 square to equal no more than ten (10) feet. ❑ 1. North arrow 0" 2. Property boundaries and dimensions 3. Names of adjacent streets 9"" 4. Driveway/s &O"S. Major features such as ravines, seasonal creeks, bodies of water, etc. ❑ 6. Septic tank and drainfield location, existing or proposed, and distance to r _ closest structure J] 7. Sewer lines ❑ S. Wells and/or water lines ❑ 9. Neighboring wells within 150 feet ❑ 10. Paved surfaces (patios) ❑ 11. Structures, existing or proposed, _ together with setbacks (distances to property boundaries) ❑ 12. Easements for access or utilities ❑ 13. Arrows showing direction of slope -- assume an elevation of 100 feet at one lot corner and indicate the other lot corner elevations in relation to it. For applications adjoining shorelines, INDICATE: ❑ 14. Ordinary high water mark ❑ 15. Top of bank, if over 10 feet high ❑ 16. Slope of bank in degrees r Indicate scale of plot plan: One inch equals _ (Grid is in 114 inch squares) c VICINITY MAP (directions to your property) JEFFERSON COUNTY UNIVERSAL PLOT PLAN AND DEVELOPMENT APPLICATION . (This is not a permit) Fill in the following information as completely as possible _ _ �- /� 1 PROPERTY VAM NAME n7li?. f /�%�5• �• • �•, 0 i 44; Ie S PHONE 3 7 - 0S3 y� MAILING ADDRESS RO CITYISTATE Q4- -udt,00' ZIP 9C33�s 1 I� �rr 1 different), �i%%l %�Of+�'��it'GC /d1L�. w PHONE ` MAILINGDDRESIZEDREP circle ane) / M V ei LudLa9A) SEPTIC DESI6IH R PHONE MAILING ADDRESS 1 GENERAL CONTRACTOR YJAft � M� •' 4,071 leu �iQ-A MAILING ADDRESS '311 MMS view of PHONE r. r Pb&4' Ludto W } STATE LICENSE NUMBER EXPIRATION DATE ARCHITECT PHONE E NAILING ADDRESS cAk jsAl Rd. LOAN LENDER NAIEIBOID HOLDER NAME SAMPLE PLOT PLAN MAILING ADDRESS PHONE N PROPERTY BOUNDARIES DRIVEWAY i .vF , SETDAM IN FEET PRovosEa suILnlRe �} LOCATION SEPTIC ERA LOrATION OF WEu. TOP OF BANK (IF APPLICABLE) SITE ADDRE- 911WROAD NAME Zo P,P�lN4 a e4` ZIP CODE X365' LEGAL DESCRIPTION - SUBDIVISION SUBDIVISION NAME• A 4 LOT BLOCK DIVISION TAX NUMBER 9 DIGIT PARCEL NUMBER SECTION TOWNSHIP. r-1; NORTH RANGE ISM p DESCRIPTION OF IMPROVEMENT: i PLEASE FILL OUT ALL OF APPLICATION +*** Dear Property Owner: Please fill this form out as completely as possible. The legal description and 9 l digit parcel rumber away be obtained from your tax statement or from the Assessor's Office in the Jefferson County Courthouse. Please make yourself at least one copy of this form so that you slay use it for future t development of your property.''* Nailing address: Jefferson County Permit Center, 621 Sheridan, Port Townsend, WA 98368 4 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 plot plan identifying these items. ALL SPACES MUST BE FILLED IN. Office Use Only Date Fee Recpt�__ Check____ Case # If information is not available enter (NV) or not applicable (NA). APR - 1 2003 Type of Evaluation Evaluation of on-site sewage system D Evaluation of drinking water 13 Evaluation of on-site sewage & drinking water Reason for Evaluation C1 Routine Operation and Monitoring Inspection 19 Real Estate transaction 0 Complete a Permit # 0 Building Permit Review and/or no septic permit on file 0 Other , explain Tax Parcel #��®p�.�(® Permitted System dyes no Permit/case # SEP --5 Subdivision,,Division, iivision, Block and Lot(s) IP697K- Thtok q4 Lot Sizea Acre or Dimensions X Current Owner waw \k Q-xl Site Address_ Q® Owner Phone # �� ®���j� Q(,p Previous property owner name(s) - (NN if not known) ��h Directions to Site N� h Vj- �Z "I Vn A. _ %® a-- t� Date System Installed s�Age .of Dwelling ` # Bedrooms HouseOccupied �G yes no, vacant how long? Who installed system? 7,= - Send completed report to: Owner Name�� Mailing Address 6n;emaivfax Sty- Q 41-7--la2L S 1 b3 Z Reaitor or Other Representative Name Mailing Address Phone/email/fax Include the following items on your plot plan: ❑ Property boundaries ❑ Wells ❑ Names of adjacent streets ❑ Septic tank ❑ Driveways and parking spaces ❑ Drainfield (enter NN if unknown) ❑ Surface water (ponds,creeks, etc) ❑ North Arrow ❑ Buildings(residence, sheds, garages, etc) PLOT PLAN F, U 1A NOT TO SCALE Permit # or Parcei R..�....,e.,,, 2 of 4 ENVIROvI HECY, LLC. 1612 Hastings Ave. W. Fort Townsend, WA QMW PH 360-379-9400 Evaluation of an Existing Onsite Sewage System Date of Inspection ®3�� 'IS Inspected by� �`� _ �j�►�y Ro0-l� �LLcN Water Supply (fill in only if water supply is being tested in this evaluation) Sample was taken Yes No Sample Results - Well casing 12" above ground Yes No Sanitary Seal in place Yes No APR _ 1 2003 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 # Bedrooms/gallons per day indicated in County Health Dept. records for this case LISN #1 - Seotic Tank Tank size I—SL-A gal. single compartment two_compartment ems- $ material Riser to grade on inlet ves )_ no. Riser to grade on outlet jleS no Condition of tank__good needs repair, describe 1st comp. Scum (top layer) n. sludge (bottom layer) in. 2nd comp. scum in. sludge in. Was ground water observed leaking into tank ? ves "_ no If yes, where was water observed Condition of baffles: Inlet: X 4 repair material Concrete) Outlet: oo � needs repair material VC oncrete) Screened Outlet -7)�.,__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 no (if no skip to section 3) #2 - Pump Chamber Tank size gal. Material. Riser to grade? yes no Condition of tank qood 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 ves 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: yes_no Permit # or Parcei Documentl 3 of 4 Evaluation .& an Existing Onsite Sewage System #3 — Drainfield Appropriate Vegetation in area yes no. Describe vegetation Indications of surfacing sewage (check one) yes , if yes, describe and diagram on plot plan no drainfield area is overgrown and not observable Signs of parking/driving in area ves no drainfield area unknown Ground settling or erosion ves -no overgrown/not observable Monitoring Port Observations (if present): Residual Head ves, # of inches no Ponding in trench ves, # of inches of ponded effluent no Repair area is? Available as shown on permit XNone evaluated or shown on permit Addendum is attached for evaluation of Treatment Unit or detailed evaluation of drainfield es -! l no COMMENTS (attach additional sheet if necessary): APR ®�%�t"'��. � ���-►� ice(" WAS O'A'K-+� � ®�'�' r eJC1 �IA 0>94cy-zo \000 —X -1 feA>i9Le�-sPecT+6p. SEE ATTACHED ADDENDUM Was a System Problem Identified? Yes if yes, what section #. Nom 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 my direct observations at the time of inspection. L'.>� �®� Nae/Signature Date m 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 D=mentl 4 of 4 KV -Z0 elaxst lo '&e 10gT£9.Wi P Do SEE ATTACHED ADDENDUM Was a System Problem Identified? Yes if yes, what section #. Nom 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 my direct observations at the time of inspection. L'.>� �®� Nae/Signature Date m 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 D=mentl 4 of 4 #��9� DATE 0`331v3 ADDENDUM ADDRESS c t,,PL+ OWNER Enviro Check, L.L.C. 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, 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 report/evaluation. 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 lines/boundaries 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/boundaries are approximations and do not indicate legal property lines or boundaries. Companv Enviro Check, L.L.C. 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 accordance with Jefferson County Ordinances, and to the best of my ability, correct. e Wurtsmr Co -Manager Weather Conditions SAMPLING (Septic tank) Date - PH Result - DO Result - Temp. Result - MEASUREMENTS Counter Setting - Hour Meter - Water Usage (Ave.GPD) Mete Squirt Height (In feet)- APR — 1 2003 FF VIEN t - 903 East Caroline 'Port Angeles � / 1 A1'ELISCAMON IS � BEMY IUM TO t MSTALLAW Am m -1 - euua - CN TEM R ' -,R1DT. MM AL DTTAT.1 :RWT PIAN GIT.0 D TIM. NOLI.0 MM .IIWWJUT=—.' 1.. Property lines 7. Driveways,r Ratiosv its etas. 2. Location oY building 8, Streem or bodies of water nearby —_ -_3,.. Location of septic tank g.. Location .of - percolation test holes 4. Location of drainfield 10. Septic tank Milions 5• SiopB- of land n. length- of propwed drainfield 6. 'Vater 3 ines . and veu.jif - .112, Depth to water if enomatered Pere, No. 1,F Bert. No, 2 Pere. No. 3 • �• t• • lid;. 'ICy+"' 4: Pepth ot hole Time required to seep last 6 inches Percolation rate (divide time by 6) T►'pe of SOU - �t '„Y• w:• • oda, r � Nor lr , . , . •„ F„► • y. , - • u • . � 4. • kr Y�. � y�. ;i;i "f r�' r- � Y> •t t��C .y y r . .. .. �* � x1 ;-.ZXMTUH . PLAN UN WID bl;LUW . Parcel Details Page 1 of 2 Parcel Number: 5400456 ! SEARCH Parcel Number: 990400456 Owner Mailing Address: JAN BRUUSGAARD KATHRYN A BRUUSGAARD 20 RAINIER CT PORT LUDLOW WA983659708 Site Address: 20 RAINIER CT PORT LUDLOW 98365 Section: 8 Qtr Section: SE1/4 Township: 28N Range: 1E Sdiool District: Chimacum (49) Fire Dist: Port Ludlow (3) Tax Status: Taxable Tax Code: 231 Planning area: Port Ludlow (7) Sub Division: PORT LUDLOW NO. 1 Assessor's Land Use Code: 1100 - HOUSES (single units, non-farm) Property Description: PORT LUDLOW NO. 1 1 AREA 4, LOT 60 1 1 1 Click on photo for larger image. 0 Printer Friendly Perms D r Dto ax History Ma Parcel IPlats & Sury s 1+44+.•�i«n:n:r i.n, sn�iss.nnw «rn «n lnnnunn�rn ��n<.nn��r.ersr.o�antni� nm. Z��i�. �iiZ Map Output Page 1 of 1 ArcIMS HTML Viewer Ma 8�Q4GQ461 r - QW40W4 �.-�s__ �--___ ! ---_ : Legend Se9aded Featums Q 103 -� _ -- III ' - SrateEne Phat®S-H MOWN" M Tolim A®OVGQds^$ ... - — -- _ . �' " ` {�, 00040040 �9$AQ400M 31f RXQV CceLs --' - - - _ d Road Systain m- OW4"106 giii74Q41GCS 090700=-= _ - - - , 00000= i v Ip 4 , I , am I Amflm f �' s sl + s � t {P 9 96040015M pt -_ __Olp � 1 � tl, OOXO= (� !Afto= i f i 89410= 9mame _7 ID~ +� ,I 96G1�P19Q 1lapmpmwidad byJa�nGouoiyii1S,, s � `' FOR INFORMATIONAL PURPOSES ONLY - Jefferson County does not attest to the accuracy of the data contained herein and makes no warranty with respect to its correctness or validity. Data contained in this map is limited by the method and accuracy of its (lection. ning information is based on the 1998 Comprehensive Plan Map and does not include changes made ring the 1999 Comprehensive Plan amendment process. Zoning designations must be confirmed with the Ee artment of Community Development. APR -1 2003 i Jefferson County Department of Community Development 621 Sheridan St., Port Townsend WA 98368 (360) 379-4450 ■ A �r� �f d3 �l MONITORING INSPECTION CERTIFICATION The system serving /Ao 9CL-A parcel # 'A.' C(Cie) y M *SZ o , permit # (-o(!D( ` � was most recently inspected on �- - C3 by ,D � � ��\ S ,m i"4\ . -as specified in Jefferson County Code 8.15.150. The above referenced system is in compliance with the Monitoring/inspection schedule identified in Table 1 of Jefferson County Code 8.15. k!Q See report completed for information on the condition of the onsite sewage system. aREQUIRED OR RECOMMENDED REPAIRS/MODIFICATIONS 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�� 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 or4uture system performance. nature of Jefferson County Employee 1 r Isahh I:11,1.1 I'I) I ORNIS MONITORINO INSPECTION CGRTIPICA HON doe Date Screen: 01 Parcel # 000990400456 Geo Cd 282108407231 PORT LUDLOW NO, 1 AREA 4, LOT 60 Mode' INQUIRY Auto Roll: OFF Nbad Cd 3332 * Taxpayer Cd BRUU 0800 BRUUSGAARD, JAN T/P Chg Dt 9/13/2000 * Title Owner T/P Chg Usr JODI Tax Code 0231 Status Tx TAXABLE Land Use 1100 RES -SINGLE Affidavit 90429 Vol/Page / Ch Code SIC Cd I I A AI IA n /0%1- Inn A_ _ _ 1 A A APRR TLAR