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FOR RENEWED_FOR ONE YEAR W; H1t.is)C''}5 f31104 EXPIRATION.
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JEFFERSON COUNTY HEALTH DEPARTMENT
802 SHERIDAN AVENUE
INSTALLER ,P7 ``a4-- PORT TOWNSEND, WASHINGTON 9836E RECEIPT NO. '7
/ (?06) 365-0722
BUILDER _ DATE �^ -8'.4'
SEWAGE DISPOSAL PERMIT
4ac:✓i 0( -OCR 2.1-1
Owner Address L-f� 5G 7 Phony E r._
G s ---% 9 �`'' G d re
Directions for locating site 9-2_-A-v-e, ---1--r`zz."` /' --I/ -4.-4--.-t � ,, _ o � �
INSTALL NEW SYSTEM REPLACE SYSTEM O PARTIAL REPAIR 0 TANK/DRAINFIELDO. 8 co 4
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TYPE OF w o on NO. OF SITE 0 Z
BUILDING <-azi-Kc., BEDROOMS -5 BASEMENT krone- -SIZE /07 9/
Previous site evaluation by SOIL TYPE DESCRIPTION a- -- '- rk J m►ggeCF
Health Department
Yes No `- 1) 6 UL/ /,-�-�'-- °�'.e'-'Y' Z -
X., v.,';,e. 7. f-P-4- 5--1 }-,e)...,,I. el r„..„4„
Depth to maximum seasonal
water table
Source of potable water supply 2) ® J� Q
Public Private X l -S °7'°"°� A- U - .4
Source type: Drilled well yS 2
Other ell R 3) C, - a LI _},L_14- / d� � o
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EVERY APPLICANT HAS THE RIGHT OF O
APPEAL AS PER JEFFERSON COUNTY Z
ORDINANCE 2-77. O( 4) C^ a,'- h.�L-- ,- ,��� v C.,�, ti\
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SIGNATURE OF'APPLICANT
ANY REJlavAL OF OR MAJOR DISTURBANCE OF SOIL IN THE PROPOSED OR APPROVED DRAINFIELD o 0
AREA MAY CREATE SITE CONDITIONS THAT ARE UNACCEPTABLE FOR THE INSTALLATION OF A A
SEWAGE DISPOSAL SYSTEM. ANY CHANGE IN BUILDING OR SEWAGE DISPOSAL PLANS INCLUDING
PLUIBING STUBOUT LOCATION) AND/OR LOCATION OF HOUSE OR DRAINFIELD INVALIDATES THIS
PERMIT UNLESS PRIOR APPROVAL IS OBTAINED FROM THE HEALTH DEPARTMENT. (Call Health Dept_
for final inspection). STUB OUT PLUMBING ABOVE_ OUNI� FOOTING, O
Drainfield Length /1'0 t Trench width ? ' Trenches dept Mir o.lines 3 Tank size /00-(T) >
Soil type and applica io rate used for design c GPD/ft2- - 1, Q r
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COMMENTS: e� C` ,, L. i) C o-r, '"'-- In
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.APP''oVEO \ DATE INSPECTED ARTIA FINA DATE n
I cerii! at this sy em was installed in a manner approved by the Health Department. r-
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INSTAL R'S SIGNA URE DATE DATE INSTALLED of
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cc: O'er, Building Department - 8/25/86
JCHDI7-84
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EFFERSON COUNTY HEALTH DEPARTMENT No.: '4269 •
Multi-Service Building -2nd Floor
802 Sheridan Avenue Fee: $15.00
Port Townsend, Washington 98368
385-0722 Date: 6-22-78
Applicant: Rob Rucri Sec. 17 Twn. 25 Rg. 2WWM
Address: Stan Johni roa LEGAL DESCRIPTION(DIV.,BLK.,LOT)
P.O. Box 88 mg}�
Ari nnnD, WA 98320 IMP RIMI ATING SITE(DRAW MAP ON BACK)
Phone: 796-4601
THIS DOES NOT CONSTITUTE Site size (11 Al
APPROVAL OF A BUILDING OR
SEWAGE DISPOSAL PERMIT. Seller None
Buyer None
I request this site evaluation for 1 single family residence or
INSTRUCTIONS: A minimum of two soil log holes at least 4 feet deep, 2 feet diameter, and 50 feet apart must
be dug in the proposed drainfield area and flagged before the evaluation is made.
A site evaluation of the above property was made on June 22, 1978 by this department
and your request has been:
❑ APPROVED — Pending submission of a completed sewage disposal permit application.
® CONDITIONALLY APPROVED — Providing conditions listed below are met and submission of a
completed sewage disposal permit application.
❑ DENIED.
COMMENTS: Keep drainfield on high ground. Well no closer than 100' to drainfield.
Soil Log: (1) 0 - 22" Silt
22"- 39" Sand with some silt
Respectfully,
(2) 0 - 22" Silt
22"- 40" Sand with some silt
SANITARIAN
Larry Anderson
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