HomeMy WebLinkAboutSEP2019-00140 JEFFERSON COUNTY ENVIRONMENTAL PUBLIC HEALTH
oti:N-um615 Sheridan St.
Port Townsend, WA 98368
ow,� www.jeffersoncountypublichealth.org
Public Health Phone 360-385-9444 Fax 360-379-4487
ON-SITE SEWAGE DISPOSAL PERMIT
PERMIT #: SEP19-00140 Date Received: 06/10/19
Date Issued: 10/08/19
SITE ADDRESS: 3504 UNDIE RD Date Expires: 10/08/22
FORKS, WA 98331
APPLICANT: UPPER BOGACHIEL RETREAT LLC PHONE: 360-640-0004
3382 UNDIE RD
FORKS WA 98331-9461
LEGAL DESCRIPTION: S1 T27 R13W TAX 5
PARCEL#: 713011004 Section: 1 Township: 27N Range: 13 W
DESIGNER: CHRIS ELSTROTT PHONE: 360-249-8447
128 N RIVER ST
MONTESANO WA 98563
SYSTEM DESCRIPTION: CONVENTIONAL TRENCH
No. of Gallons per Day: 240 Type of work: NEW
Drainfield Trench Septic Tank
Length: 100 feet Width: 3 feet Depth: 36 inches Size: 1,200 gallons
DISCLAIMER-This approval is for an on-site sewage system that meets the state and county standards in effect on the
date of application. This approval for an on-site sewage system DOES NOT assure you of any other County approvals. For
example, it DOES NOT GUARANTEE that you will later obtain permission to build a permanent residence or other structure
on this parcel. Any future application will be separately judged by the rules and laws in effect at that time. All construction
and development activities must comply with all permit conditions, state and local codes, and Recommended Standards and
Guidance documents in effect when the permit is issued.
The property owner is responsible for the accurate location of all property lines.Any removal of or major disturbance of soil in the
primary or reserve drainfield area may create site conditions that are unacceptable for the installation of a sewage disposal system.
Any change in drainfield or tank location may invalidate this permit unless prior approval is obtained from the Jefferson County
Environmental Health Division. If during excavation or development of the site an area of potential archeological significance is
uncovered, all activity in the immediate area shall be halted, and the UDC Administrator shall be notified at once.
Permit issued to CONSTRUCT, ALTER, REPAIR OR MODIFY AN INDIVIDUAL SEWAGE DISPOSAL
SYSTEM IN JEFFERSON COUNTY, WASHINGTON
This permit is issued for a period of three years (unless otherwise stated above) in accordance with
Jefferson County Rules and Regulations for On-Site Sewage Systems, codified in JCC 8.15 as amended.
This permit may not be renewed.
C Rr {-
Jefferson County Environmental Health Specialist
This permit with conditions must be onsite during all phases of construction
HEALTH DEPARTMENT MUST BE CONTACTED FOR FINAL INSPECTION.
SPECIAL CONDITIONS APPLY - SEE REVERSE & ADDITIONAL PAGES
18.) This system as designed and approved is sized for only one single family residence. It is not sized
for an Accessory Dwelling Unit (ADU). The minimum daily design flow per residence is 240 GPD.
19.) The project shall adhere to the Best Management Practices (BMPs) for the control of stormwater,
erosion and sediment during construction. BMPs shall address permanent measures to stabilize
soil exposed during construction, and in the design and operation of stormwater and drainage
control systems.
SEP19-00140 Page 3 of 3
\\tidemark\data\forms\F_SEP_Permitmod.rpt 10/8/2019
Jefferson County Environmental Public Health
615 Sheridan St.,Port Townsend WA 98368,(360)385-9444
SEPTIC SYSTEM PERMIT APPLICATION
PROPERTY OWNER ill'fiE 066",fiC4'/4 d'" "...i7124":47-- e
MAILING ADDRESS 338 ‘41/1.14Z 4''®
PHONE (no) ,6Vo e'Y EMAIL
SYSTEM DESIGNER Geed' s e4-1 T.eax- Designer Phone# 3‘i " S7., X00 V
LEGAL DESCRIPTION: Section 1 Township 27 Range/34) PARCEL# 7/3 P1/ 4:206
17
Subdivision Name rR)e -r- Division Block Lot(s)
Site address&Directions to site&test pits /r -'44/ 4/eVeI.Z- AO, 11°1WJs `3J
414"4'e 20.9,1 ow' X✓6#17- d o P`A/Ua. AaAiVe700.®dsW41z-.44_)
SOURCE OF SEWAGE/USE TYPE OF WORK Water Source
Private ./�
New t-•.'"--.. Tanks only Public Name
Residential V Modification Expansion
Commercial
Community Repair Tank') Drainfield
SITE SIZE,,2 acre sq/ft
System Type ReplacementTank(s) Drainfield_ Previous Evaluation
Conventional Designate Reserve Area 4
Alternative Redesign Yes case#.SF,o/9- No
✓ Qod/va
SYSTEM DETAILS
Number of Gallons/day Ze`P Soil type 5 (attach soil eval.) Application Rate ®.8 gal./sq.ft./day
Drainfield Length /00 ft. Trench Width -? ft. Trench/Bed Depth 36 in.
Septic Tank size /20o gal. Pump Chamber size N//4 gal.
TYPE OF SYSTEM 6.CAt✓7"
By signing the application form, the applicant/owner attests that the information provided herein is true and correct to the best of
their knowledge. Any material falsehood or any omission of a material fact made by the applicant/owner with respect to this
application packet may result in this permit being null and void. I further agree to save, indemnify and hold harmless Jefferson
County against all liabilities, judgments, court costs, reasonable attorney's fees and expenses which may in any way accrue
against Jefferson County as a result of or in consequence of the granting of this permit.
I further agree to provide access and right of entry to Jefferson County and its employees, representatives or agents for the sole
purpose of application review and any required later inspections. Staff's access and right of entry will be assumed unless the
applicant informs the County in writing at the time of the application that he or she requires prior notice. Inspections shall occur
during regular business hours. Initial here if you require notification before entry
Appeal-A person aggrieved of a decision of the Health Officer may appeal. Appeals shall be submitted to the Health Division in
writing within fifteen days after receiving written notice of the decision.
DISCLAIMER-This application is for an on-site sewage system that meets the state and county
standards in effect on the date of application. This application for an onsite sewage system DOES
NOT assure you of any other County approvals. For example, it DOES NOT GUARANTEE that
you will later obtain permission to build a permanent residence or other structure on this parcel. Any
future applica 'on will be separately judged by the rules and laws in effect at that time.
ro Owner Signature Date
FOR OFFICE USE ONLY M;' ,ZarQ
0-,'(9°1.1 PARTIAL ASBUILT ��-aG-Ii FINAL a-26';20ii
APPROVED I ® �
INSP/PUMP TEST ti/P‘ Monitoring Agreement
ALL HOLD REQ. MET
Date 10-27-IQ Fee j91.00 Rec# 6 yy 2.8°5 Check# Coin- Case#SEP 1 9-00110
G:B--ONSITE\Forms\Application Form & Info\SEP_Perni.t Application 11/26/18 SAR
Jefferson County Environmental Health Dept.
615 Sheridan St., Port Townsend,WA 98368 360-385-9444
SOIL EVALUATION
Property Owner/s PP/P,-12 ge,l 4'' . deir#7 "-IC- System Designer CJ#fis . SrI2 air
Date soils logged: 9'27-/9 Logged by: ..5 /s €44772+7
LEGAL DESCRIPTION:Section / Township 27 Range/3 u Parcel#/s 7/3 D//Gtr y
Include soil textural characteristics and depths at which significant changes occur.
Be sure to include depth where mottling or impermeable layers occur. Use additional sheets as necessary.
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JEFFERSON COUNTY
ENVIRONMENTAL PUBLIC HEALTH
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CONVENTIONAL SYSTEM ASBUILT INSPECTION REPORT
INSTALLER PARCEL # 7/3 cp,//
Permit Owner V Z& •So6,4444-10 emir" Permit # —"wo 6'01
ABSORPTION AREA: GGG�
DRAINFIELD TRENCH , TRENCH c, TANK #OF #GAL/
Z y0
LENGTH /40WIDTH L3 DEPTH "6 mtt o SIZE a /BEDRMS
Tank Shroud/
IF PUMP AND PUMP CHAMBER REQUIRED: Size AS- Screen
Float Arrangement /1/,1
High water float—distance to top of tank/emergency storage /!///9
Dose drawdown (#of inches) ///' /1 #Gallons/Dose
Timer/Dose Counter info /t Pump Size/Manufacturer
I CERTIFY THIS TE SE SYSTEM WAS INSTALLED AS DESIGNED, PER PLAN APPROVED
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INSTPfCLER SIGN UR'/ DATE INSTALLED
nu 26 2019
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