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HomeMy WebLinkAboutSEP1975-00442Jefferson County Department of Commune Development 62,1 Sheridan St., Port Townsend . WA 98368 (360) 378-4460 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 pian identifying these items. ALL SPACES MUST BE FILLED IN. If information is not available enter (NV) or not applicable (NA). Type of Evaluation 0/ Evaluation of on-site sewage system ❑ Evaluation of drinking water ❑ Evaluation of on-site sewage & drinking water -.Qiru .Use Only Date __��- c Fee 39.10 Recpt,_ 9 133-5 Check d 3 ( (L3 Case # 2 5 , �j + Reason for Evaluation �RRoutine Operation and Monitoring inspection fid/ Real Estate transaction ❑ Complete a Permit # ❑ Building Permit Review anWor no septic permit on file ❑ Other, explain Date of evaluation �� ` ' inspected by l' Tax Parcel # b 0 (- 0 9� l Permitted System ,�es no Permit/case # SEP q, Subdivision, Division, Block a ndgLot(s) Lot Size Yio Acres or Dimensions Current Owner _ - r i 1 vii�d'4 Site Address -- f G 1 2 --5 a .L �, 1 wr' l r c1 - Owner Phone # -2(')11_ ,S 4 fs_ `� Previous property owner name(s) - (NN if not known) Directions to Situ U ,Jo D, _s-& 4, � e. Date System Installed Ucc� Age of Dwelling /� �� # Bedrooms_ House Occupied ves_no, vacant how long. Who installed system? Send completed report to: Owner ) (/ Name ,, 4� n sec) !/ c vz t cis Mailing Address Z -11c1 S io,5 i�� `. , T 1 "-n ,A v- Phone%mail/fax 3 C, 1) 3 --) x,51 Realtor or Other Representative Name � O/) v, s c c> )c �Ac' " S-0 Mailing Address Phone/email/fax page 1 of 5 EES Evaluation Fort_©7-30-04_pof ,Lncltade the following items on your. plot plam,.%.. - o Property boundaries U- h v r,( Names of adjacent streets v' Driveways and parking spaces ❑ Surface water (ponds,creeks, etc) M// Buildings(residence, sheds, garages, etc) PLOT PLAN -date prepared, 3 _ (� ,�G T 30 0( WeNs da/'Septic tank cY Drainfield (enter NN # unknown) North Arrow �r �6 :� C C, C esY e v HC, 1" 4 (1 Permk # or Parcel # Evaluation of an E item 07/30104_pctT page ? of 5 Date of Inspection 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 gro n Yes No Sanitary Seal in place Yes No Public: offsi onsite Name of System Individual: offsite onsite Is well more than 100' to drainfieldtdisposal component _—yes_ no, if not, distance Is well more than 50' to tanks and effluent transport line ___ares, no, if not, distance ONSITE SEWAGE SYSTEM # Bedroomsigallons per day indicated in County Health Dept records for this case #1 Se ttc Tank Tank size /0 r 0 _ gal. single compartment — two f compartment 5 0,1 C v r- t C material Riser to grade on inlet no. Riser to grade on outlet �yei no r Condition of tank ood needs repair, describe 1st comp. Scum {top layer}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 obsefved? n Condition of baffles: Inlet: Aood�' needs repair material (P1LC Ccamcr {i } u i o Outfit -,c •Dod needs repair material (PVC,concrete) Screened Outlet no __yes, condition dean dogged/dirty Septic tank needs to be pumped (per Jefferson County code 8.15.150 (1) (b))yes no P(,,iledl 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 gat. Material_ Riser to rade? Ves no Condition of tank good needs repair, describe Solids in Tank (see 8.15.150 no scum in. sludge -in. Was Ground water ob d ie ing int tank _ res no If yes, where s er ed? Screen around pump? no es, condition clean dirty/clogged Shroud around pump? no Electrical Components Pump operating res no, describe High water alarm functions res no, if no, describe Elec. Panel condition good needs repair, describe Pump cycle drawdown inches. Time for pump cycle mintsec. Timer Settings mintsec on mirVhrs off Floats secured: res no Permit # or Parcel # page 3 of 5 Evaluation of an Existing Onsite Sewage System _07130104_pdf #3 - Drainfield , / I Appropriate Vegetation in area ,,,!`.i�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 „ 1,� no overgrown/not observable Monitoring Port Observations {if present Residual Head —yes, # of inches no Ponding in trench # of inches of ponded effluent no Repair area is? Available as shown on permit None evaluated or shown on permit Addendum 5) is attached for evaluation of Treatment Unit or detailed evaluation of drainfield fir _ es no COMMENTS (attach additional sheet if necessary): 7-- " Was a System Problem Identified? Yes Gf yes, what section #. No_Z— 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_ (J ! amelS' re 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 fmdkigs only. Permit # or Parcel # 1 ' (� / 7 L1 page 4 of 5 Evaluation of an Existing Onsite Sewage System _071Q/Q4_pdf 903 E. Caroline OLYMPIC HEALTH DISTRICT Permit No. Port Angeles SEWAGE DISPOSAL PERMIT APPLICATION Submit in Duplicate Buildex Court House Port Townsend Date a ���, o Z DRESS 1 Z G Q A N'f PHOPTE��C(o i I DIRECTIONS FOR LOCATING SITF{_ FL 97$T 9:b e F `' ywrh P fro AD as t Rte Fj V" L. L e k . APPLIC4TION IS HEREBY MADE TO: INSTALL NEW SYSTEM SIR EXISTING SYSTEM f R�Ivr1��Q►."e YPE OF BUILDING N0. OF BED 0�'IS BASEMEN'S SITES NAME OF INSTALLER DRAINFIELD LENGTH.1p._WIDTH ��DEPT �#LINES � �SEPT�G� TANK 'SI DRAB! A DETAILED PLOT PLAN BELOW. SEE INSTRUCTIONS, SOIL TYPE �o PoSE1 @ )pwE �p S.; TE L ,4 pof 1 A _ Mo n wry + �j I JJV%A lJ..LVltl VAI Q.LLJ , .LdYYKLiLK1L"JA7 L11A.0 PERMIT UNLESS PRIOR APPROVAL OBTAINED FROM THE HLALTH DEPARTMENT. DATE OF INSTALLATION''` - SIGNATURE OF APPLICANT>C APED �v DATE NSPECTED BY .. SANITARIAN'S COTtMLNTS �� ....e Ft__.._r...._... I CERTIFY THAT THIS SYSTEM ',?AS INSTALLED IN THE MANNER APPROVED BY THE HEALTH DEAPRTMENT,� TF INSTALLERS NAME