HomeMy WebLinkAboutSEP1975-0045540 c JEFFERSON COUNTY PUBLIC HEALTH
615 Sheridan Street • Port Townsend • Washington • 98368
www.jeffemoncountypublicheafth.org
Donald Gann
201 Seamount Dr.
Brinnon WA 98320
(360)796-0092
RE: Contacting Designer
201 Seamount Dr.
SEP75-455, parcel# 993-500-031
Dear Mr. Gann:
March 20, 2007
3/aw/07 f}s2r�
Before issuing any building permits for your property it is necessary that you contact a licensed
septic designer to resolve the following issues regarding your septic system. These are the issues you
would need a designer to address and have verified by the Jefferson County Health Department:
1. Preparation of an as -built drawing by a licensed desinger, locating on-site components: septic
tank, D -Box and opposite end of one lateral
2. Designate reserve area
3. Make corrections to problems noted in Evaluation completed on 8/23/06.
a. Portion of concrete slab over septic tank needs to be removed
b. Outlet baffle deteriorating --needs repair.
If you have further questions please contact this office at 385-9444.
Sincerely,
/0��t
Angela Pieratt
Environmental Health Specialist
360.379.4489
cc: file
encl: copy of SEP75-455, 8/23/06 EES & list of local designers
COMMUNITY HEALTH
PUBLIC HEALTH
ENVIRONMENTAL HEALTH
DEVELOPMENTAL DISABILITIES
ALWAYS WORKING FOR A SAFER AND
NATURAL RESOURCES
MAIN: 360-385-9400
HEALTHIER COMMUNITY
MAIN: 360-385-9444
FAX: 360-385-9401
FAX: 360-385-9401
903 E. CaroMne OLWI;EC HEALTH DTSMCT
Port Angeles "'SMIKGE DISPOSAL PERMIT APPLICATION
Submit in Duplicate ,
Court house
Port Townsend
Pemit No.4
Builder
hate - / 3 7
PHO '
. .0.60 93,7-3009 �
APPLICATION IS HEREBY MADE TO: INSTALL NLV SYSTEM_,A REPAIR EXISTING SYPT M
® a s� �-f� �
F B I1�G� NO. C EDROOMS BASEMENT 'SITE -S S'�ALLER
DRAINFTELD "LENGTH J IDTI# J I DEPTH 30 If #LINES_J_SEPTIC TANK SIZE
DRAW A DETAILED PLOT PLAN BELOW. SEE INSTRUCTIONS. SOIL TYPE � o
+' AM HA�IN BUILDING OR SLYAGE DISPOSAL PLANS, LOCATION OR SITE, INVALIDATES THIS
PERMIT UNLESS PRIOR APPROVAL.OBTAINED FROM THE HEALTH DEPARTMENT.
DATE OF INSTALLAT/ION SIGNATURE, OF APPLICANT ,, s
APPR OM DATE
INSPECTED BY c�?,.r� DATELS l !'-
SANITARIAN 1 S COMMENTS:
I CERTIFY THAT
HEALTH DEAPR.TM
IN THE MANNER APPROVED BY THE
6 t r.a. 6.,,, $.
Jefferson* Count}* Health Department� �' �_ Receipt. No.��
802 Sheridan Ave.
Port Townsend, WA 98368 Fee: �d ��
206-385-0722
Date:
EVAUTMON OF INDIVIDUAL SES -DISP0SAL -SY51Fhi "A?b/(R MMR SUPPLY
Informatirm Rer3uested: _4 Individual Sewacge Disposal System
Water Surely Public Private-
Applicants-
rivate
Applicants Name
Owners Name
Addrew /. 7/7
Kai 1 Completed R rcr; To :
Phone: - X.3 - 3 Number of bedrooms o7
Previous Owner, { if Known) Year Instalie
Legal Description: Section .�1 Tounship Z;�- Range .��&J
Street Address J O/ �rt�i�ia�/r f 1�.�� �� e. ,,56Pr`�✓�r/a.t/ �,J .�
Directions to property I , n R n .dl '4 ,j e /1') , `d . ,
FCR HFALTH DEPARMENT USE ONLY - DO NOT WRITE BELOW Mrs LII
S OM DISPOSAL SYS EW
Permitted system no
Installed prior to permit requirement ps --no
Sewage noted on ground at time of inspection* yes ✓no
House is unoccupied therefore an evaluation of drainfield performance is
not possible at this time.
A review of our records indicate that this system was designed to
service a 2 bedroom residence. This system is not considered
adequate for a bedroom re-sidence unless it is sized per current
regulations.
Septic tank should be pumped if not done within past 3 - 5 years.
I.; *:'"I14J L
Well casing 12" above ground yes M
Sanitary seal in place yes no
Well 100' from drainfield yes no
Water sample taken yes no
Sample results
:LnAd-l- a -A et -4144' c�zG-�t� L�fff e�.�e ,.� i-, tZ;2 5ehe - .mak . Ce -,A -J
DateTime M:'#5p'''
Environmental Health sp-cialis}
* This report does not r0n8t tote a m3arantpe, either written or implied, that
the stem ,will continue to ftnrtitin properly. Thispos~t constitutes a
..T710 f nrlfngc only.
.j
9
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' JE1-E.sdr,. caU:rrf HE LMIA SEPMMMErT
LNDt'lIDUaL ShiiACcDISPOSAL LHS?E=o1q FORM Date
Dace
dPPRQ`:ED '[E
�� vo-- �.'�►IRQNFty.'t'i;.LIST (�
Address
Oun e r
t.esrai Deseripc:on
Residence Commercial of Bedrooms Syscem Installer
SEPTIC TANK 3
Syscem Desi ner
Commercial ✓ Nan commercial � Measurements: L H_ yA
Con'scruccion 42ccrial Q�wncve k
Lig. Cap.
DISPOSAL n ELD
Exc. Oepch Width Total Lenge Sq. Ft.
Rock Type Depth Under
Aver
Engineer Design YesType Eazineer Aapra;-1 Letter Yes
Well SO feet from tank 100 feet from leach field
Well installed at time of septic system inspectioo Y - No Public Water
Comments: Ashes -i 1$,®� L-ar4ne-e,
C
cence&4e bafHe-S-� rti�ucl'
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,Tefferann Crnmiy A, AWd Riji1ding Department
PO Box 1220
Port TnwnRend, WA 98368
2nfs-385-9141
PF.RMTT #....:FiT.T)91-0670 DATE. RRCFTVEn.:09/17/91
STTF AnnRF.SS : 201 SF.AMOTINT DR
:RRTNNON, WA 98320
-------------------------------------------------------------------------------
OWNER.......:DOW LOREN7.FN PHONE: 839-3008
MATT.TNG ADDR: fi31 S 298TH
:FEDERAT. WAV WA 98003
-------------------------------------------------------------------------------
CONTRACTOR..:NO CONTRACTOR PHONE:
MATLTNG ADT)R:
CONTR. T.TC #: F.XPTRATTON DATE.:
-------------------------------------------------------------------------------
ARCHTTECT/..: PH0NF.:
T)F.STGNF.R .... .
MATLTNG ADT)R!
-------------------------------------------------------------- - ------
PARCEL NO ... :993500031 HFAT.T : _
LEGAL T)FSC.. STR 31-25-02 WWM, TAX # RV: DATE:
LOT 1 , BLOCK 4 , SF.MOTINT ESTATES SHO F.T.TNFS :
RV ! DATE!
nESCRTPTTON OF TMPROVFMFNT: MORTT.F HOME TNSTALLATTON t_.a_Lt's ^�P` e; ( -Icy q d !1
---------------------------------------------------------=---------------L-��-- f
RTITT.T)TNG TVPF...... !MOR BEDROOMS--- BATHROOMS-- MATN FT....: 0 of
TVPF. OF TMPROVF.MF.NT ! NF.W FXT ST .: 0 EXT ST .: 0 2NT) FT.....: 0 of
GARAGE/CARPORT.....: PROP..: 2 PROP..: 7. 3RD FT.....: 0 sf
WOODSTOVF.......... : TOTAT..: 2 TOTAL.: 2 RASEMENT..: O of
TIRO OCCTIPANCV GROTIP:R3 SEWAGE nTSP..:SFPTTC CARPORT...: 0 sf
TVPF. OF CONST ......: WATER STIPPT.V .: CWF.T.T. GARAGE ....: 0 sf
TINTTS. ! 0 STORTF.S:O HEAT TYPES.: T)F.CKS..... 0 sf
nTMF,NSTONS!-------MORTLF ROME ------ COMMF.RCTAL: 0 of
FRAME, TVPF: MAKF.:FT.FFTWOOT) VR:91 TNT)TISTRTAT.: 0 :3f
EST COST.$: 67000 ST7.F.:28 X 4n RANK HT... :0 ft
PROT GRP..! 1288 SH SETRACK:O ft
-------------------------------------------------------------------------------
Owner/agent---------------- FEES --------------
S i c, jnature : \ type ammint by date rerpt
Date:
Taaued Ry!
Tate:
PRMT $ 100.n0 AK 09/17/91 59714
R.C. $ 4.50 AK 09/17/91 59714
------------------------------------
$ 104.50 TOTAL
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SEP 1 8 1991
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q Jefferson County --�- --.
t Environmer&tal Health -Department
SRI I • g
Application For Determination of '
Adequate Potable Water Supply #---�--•
LTH
Jefferson County Resolution #99-90 requires building permit applicants
to provide eVidence of an )adequate potable water supply.
'Name b n1 /0 PhoneCH
Address /v 3 / ) ,:;,?��98 ) J
9y �'®3
Assessor's P
Legal Descri
Site Address
Type of Evidence* (check one)
Valid Water Right Permit (attach copy)
Approved Public Water (attach letter from purveyor that the
system is capable of and will supply water. Include State ID
number. Environmental Health will determine if system is in
compliance with State Drinking Water Regulations).
Individual Well (attach copy of well logs including production
test results and lab analysis for water quality parameters -
total coliform, Nitrate -N, primary inorganids - and plot plan.
showing location of well with respect to proposed sewage system,
buildings, driveways and surrounding properties).
Office Use:
a) Watgr Right Permit#
b) Public Water Supply SAaw, aw.fis
Name of Supply (,u,,.. _ ,(&,& Washington
In Compliance yes no.
c) Individual Well
Driller Name Date
Depth Prodyy1't�
Meets Water Quality�t4ndar
Applicatiga� App�i owed v /De�ied**
a
State ID1_XtL X
Drilled
yes no
Not required
Date
* A temporary moratori shi
RMUURT bblo&flib WUIV MUIVIT Y 4"Uz
4± Z,/ 19/
1.date
TO WHOM IT MAY CONCERN:
POTABLE WATER IS FURNISHED TO0)/LOTS OWE . DIVISION I—, OF
SEAMOUNT ESTATES COMMUNITY CLUB BY WATER SYSTEM NUMBER 76986X.
J HN W. OLSON
ATE% MANAGER
.TFF'F'1�R�[')N C'�C3'CZ�N T.T)T N� A7�'laT.T C:fi.'TT C'7N
Tpf fprron Crnm y oraV, U 'AWd Building T)ppartmpnt
PO Box 1220
Port- Towngpnd, WA 98368
206-3a5-9141
PFRMTT #....:RTM91-0Fi70 HATE RFCETVED.:09/17/91
STTF AT)T)RFSS : 201 SEAM017NT nR
!RRTNNON, WA 98320
- - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - --
OWNF.R.......:nO'N LORENZEN PHONE: 839-3008
MATT.TNG ADDR : 631 S 298TH
:FEDERAL WAV WA 98003
-------------------------------------------------------------------------------
CONTRACTOR..!NO CONTRACTOR PHONE:
MATT.TNG AT)T)R :
CONTR. T.TC #: EXPTRATTON TATE!
-------------------------------------------------------------------------------
ARCHTTECT/..: PHONE.:
DESTGNER .... :
MATT.TNG AT)T)R :
--------------------------------------------------
- ------
PARCEL NO 993500031
HFAT.T
LEGAL T)FSC..:STR 31-25-02
WWM, TAX #
RV: DATE:
LOT 1 , BLOCK 4 , SF.MOTTNT
ESTATES
SHO F.T.TNFS :
RV! DATE:
nRSCRTPTTON OF TMPROVF.MFNT !
-------------------------------------------------------=
MORTT.F. HOMF. TNSTAT.T.ATTON
_3
°---='=�� _ « _L_1�1a _V.f
RTTTT.nTNG TYPE ...... !MOR
BEDROOMS---
BATHROOMS--
MATN FT....! 0 of
TYPE OF TMPROVF.MFNT:NFW
F.XTST.: 0
FXTST.: 0
?WT) FT.....: 0 sf
GARAGE./CARPORT.....:
PROP..: 2
PROP..: 2
3RD FT.....: 0 sf
WOODSTOVE.......... :
TOTAT..: 2
TOTAT..: 2
BASEMENT..: 0 pf
TTRC OCCTTPANCV GROTTP:R3
SEWAGE T)TSP..:SF.PTTC
CARPORT...: 0 of
TVPF. OF CONST......:
WATER STTPPT.V.:MELT.
GARAGE....: 0 sf
TTNTTS.: 0 STORTES!O
HEAT TYPES.:
)
DFCKS.....: 0 sf
T)TMFNSTONS !
-------MORTT.F. HOME------
COMMERCTAT.: 0 Rf
FRAME. TVPF !
MAKE : FT.F.F.TWOOT) VR: 91
TNDTTSTRTAT.: 0 sf
FST COST.$: 67000
ST7.F:2a X 40
RANK HT... !0 ft
PRO.T GRP..! 12aa
SH SFTRACK!O ft
-------------------------------------------------------------------------------
Ownpr/agent
----------------
FEES --------------
S i gnature :
type ammint
by date rpr:pt
PRMT $ 100.00 AK 09/17/91 59714
T)atp!
R.C. $
4.50 AK 09/17/91 59714
Tasupd By:
Date:
------------------------------------
$ 104.50 TOTAL
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Jefferson County --- �.
Environmental Health Department E'
SRI i NO
Application For Determination of '
Adequate Potable Water Supply<<._�;,
LTh
Jefferson County Resolution #99-90 requires building permit applicants
to provide esti/dence of an adequate potable water supply.
'Name iia nl Phone/Hm.�+
Address /v 3/ C� a 99" 7 H k
9T 003
Assessor's Parcel".rF
yy.j SDD D.j /
Legal Description ;Property o .�
Site Address RIAI O eaA
Type of Evidence* (check one)
Valid Water Right Permit (attach copy)
_ Approved Public Water (attach letter from purveyor that the
system is capable of and will supply water. Include State ID
number. Environmental Health will determine if system is in
compliance with State Drinking Water Regulations).
Individual Well (attach copy of well logs including production
test results and lab analysis for water quality parameters -
total coliform, Nitrate -N, primary inorganics - and plot plan
showing location of well with respect to proposed sewage system,
buildings, driveways and surrounding properties).
Office Use:
a) Water Right Permit#
b) Public Water Supply sp" awtifi 5
Name of Supply (eG,,,, _ Ck. h Washington State ID# jdX
In compliance yes no.
c) Individual Well A,
Date Drilled
Driller Name C `�
D•h
Depth Prod134dtion
Meets Water Qualit ndards yes no
Applicatign App oved a ied** Not required
,,,� W111,111111
* A temporary moratori sdall be placed on approval of alternative
water supply syst s until appropriate design and construction
guidelines have be n established.
** Appeals shall be filed in writing within 15 days. pursuant to Jefferson
County Health Department Policy Statement #2-88.
9/90:WATERSUP
^ 7r
'7 /a �' - -
TO WHOM IT MAY CONCERN:
POTABLE WATER IS FURNISHED TO O/LOTS DIVISION I-, OF
SEAMOUNT ESTATES COMMUNITY CLUB BY WATER SYSTEM NUMBER 76986X.
HN W. OLSON
ATER MANAGER
JOHN W. OLON — WATM MANAGER
-
i,, A .
r
t !4 s
T4 FE.R 8 1993
:s'.QN�0, U,wrS' -gyp q G 472'
Jefferson -County Planning and. Buic g�eparti`ent
COurthOuse, 3rd Floor.'�'�atl�`h� 4+vi�iratYy e�
t! PO Brix 1220
4 r+ If ++ r
,_ -. � _I'°�r1 �'xf ,1 �.�cr'k ! � +ti i+ 1� •,
'� 4� , Port Tawnaenrl, WA .98368
+ �4 1et1M fit, a e� xit
206-385-9141
+ti,t `. � ,i:., � i 1 - .. ,, Issi ' �`.r # � ail n'' { i+::.i •.!t
FPERMTT'.:Br,D93=00?2, r`' DATE RE;CEzVD+i4Q2/16193 ;4
ITE-
AD RESS 201 .SLAMOUNT OR,�,��
:GRIN 0 WA 19 32Q re
'-- -- -- -- - - ------- -- -- - , ---- O
PHNE 8S9 3008
OWNE2;. ...,, , • DON LORENZENiM
MAILING ADDR'- 63I S. 298TH ' ' a r' °F `� + }"
tt. Y V,',, n u
rtt t .FEDERAL WAY +w 98003
�
CONTRACTOR :NO CbNTRACTOR 'R�,+.JE v"
MAILING ADDR:
CONTR.', LIC # EXPIRATION DATA
t
ARCHITECT./ --- --- -- + - - ---- -- - --- PHONE
-
DESIGNER.. f4 fl r {
MAILING ADDR: h
PARCEL'NO ...:99350 -0$1 SEPTIC i',+!' DATE
77
,LEGAL DESC , .: STR 31 25-02 . 7WM, TAX # WATER;;' ,i DATE
LOT 1 : ,BLOCK 4 SEMOUNT ESTATES. SHOREL' NE _
BYDATE:
DESCRIPTION OF IMPROVEMENT',DETACHED GARAGEy"'
:BUILDING TYPE... i' :GAR - BEDROOMS----rBATHROOMS-- MAINry '%:, OMsf ti
TYPt'OF IMPROVEMENT:NEW EXIST 0 EXIST.. 0 Q sf
.'GARAGE
GARAGE/CARPORT PROP.. 0 PROP 0 HTED;BSMT Q sf
WOODSTOVE....;.....: TOTAL. 0 TOTAL.: 0 UNHT'BSMTt 0 s�
UEC `OCCUPANCY . GROUP . S.EWAGE DISP ..: SEPTIC :CARPORT: O..S
TYPE 'QF GQIQ$T WATER'' SUPPLY. ; GARAGE: { . , $32 6f
UNITSI: 0 STORIES:O :HEAT TYPES.: 0 Sf
DIMENSIONS: -----MOBILE HOME------ COMMERCIAL0 sf
FRAME TYPE : MAKE:* YR: INDUST.RIAT 0 s
}QST 1.sCOST . $ : 8320 SIZE : BPIyI��IT;.: 0 ' L; f
PROD'GItI?. 1288 SHx�"SETDACIi 0,'w
Owner jagent-- ---------- - --- -----
Signatuxe : type^ am b5" o"' recpt
z} PRMT $ 108.0002f;�F6193 7257
D,ata.`, ;,' PLCK $ 32'.4Q AK° `q2l 5
$/,93` b757
Z777,77
B.C. ' $ 4.50 Ake+�d , ,j'02 93 757676"
Issuec'! i Bye*9`",
0'
S
X1r'1t �i� t 1° k 0,,
.4,z� - —s r r
�;YlSy t� i {;t rY�j+it a
$ 144.90 ,TC'�A&��Itt'"
Yt�Sr
IF7.,
Vs
LEGAL DESCRIPTION: , .�
SUBDIVISION NAME ,� &A MGort .y� l=S/.n Le S LOT= /-BLOCK DIVISION_ tV�
TAX NUMBER 9DIGI� NUMBER
SECTION TOWNSHIP NORTH RANGE WM
.DESCRIPTION OF IMPROVEMENT:
" t
-----
PLEASE FILL OUT ALL OF APPLICATION:
**** Dear Property Owner: Please fill this form out as completely as possible. The Legal, description and 9
digit parcel number may be obtained from your tax statement or from the Assessors Office in the Jefferson
Count Courthouse. Please make
Y yourself at least one ropy of.'this form so thatyoumay use it for future
devetopment of your property. ****
Mailing address: Jefferson County Planning A Building Department, PO Box 1220, Port Townsend, WA -98368';
_ _- _ -
_ .... .,.. .�.. xr .w r.._ - .. -fes:`: - -
.. _.. .. _.__. -. _ ,c.__k- •_ .___ .'�--- ---- ._aa... g ,_ �-.. 2.n�..-.__.... .:� .+...-.r_. ..._�`� . +.�.�.�t��r�4_..--. __.tr._ �-:�._. --�_.. ,r -�---�_-. ____�. __ .�x_A�-ria... _ _ �--'.a_. '�.���-.-_es'4=-= " `�•�' ___tr _a._. .�-_`_-i_�.—..'::_�..>.
VICINITY MAP
(directions to your property)
y
--
JEFFERSON COUNTY UNIVERSAL PLOT PLAN AND DEVELOPMENT APPLICATION
(This is not a permit)
Fill in the following information as completely as possible
c7
PROPERTY OWNER NAME.t/A LL1 F oRc�.v z�r.✓ PHONE
MAILING ADDRESS - C31- S6
CITY/STATEsio2a %_ (t).ai► /A�l.t/ ZIP /fir
SEPTIC DESIGNER - PHONE -
f
MAILING ADDRESS
CONTRACTOR
_
MAILING`ADDRESS �3� a ti , g� �k - PHONE
STATE LICENSE NUMBER EXPIRATION DATEl
ARCHITECT PHONE
.1
MAILING ADDRESS
LOAN LENDER NAME/BOND HOLDER NAME
s
MAILING ADDRESS PHONE
SAMPLE PLOTFLAN
- --
SITE ADDRESS.
911#/ROAD NAMEO – ,Cc
��'�I_EJeu .v� t�Qr LCd ZIP CODE
Vs
LEGAL DESCRIPTION: , .�
SUBDIVISION NAME ,� &A MGort .y� l=S/.n Le S LOT= /-BLOCK DIVISION_ tV�
TAX NUMBER 9DIGI� NUMBER
SECTION TOWNSHIP NORTH RANGE WM
.DESCRIPTION OF IMPROVEMENT:
" t
-----
PLEASE FILL OUT ALL OF APPLICATION:
**** Dear Property Owner: Please fill this form out as completely as possible. The Legal, description and 9
digit parcel number may be obtained from your tax statement or from the Assessors Office in the Jefferson
Count Courthouse. Please make
Y yourself at least one ropy of.'this form so thatyoumay use it for future
devetopment of your property. ****
Mailing address: Jefferson County Planning A Building Department, PO Box 1220, Port Townsend, WA -98368';
_ _- _ -
_ .... .,.. .�.. xr .w r.._ - .. -fes:`: - -
.. _.. .. _.__. -. _ ,c.__k- •_ .___ .'�--- ---- ._aa... g ,_ �-.. 2.n�..-.__.... .:� .+...-.r_. ..._�`� . +.�.�.�t��r�4_..--. __.tr._ �-:�._. --�_.. ,r -�---�_-. ____�. __ .�x_A�-ria... _ _ �--'.a_. '�.���-.-_es'4=-= " `�•�' ___tr _a._. .�-_`_-i_�.—..'::_�..>.
Mar 20 07 11:59a
A
Jefferson County Department of Community Development
621 Sheridan St., Port Townsend WA 98368 (360) 379-4450
Evaluation of an Existing onsite Sewage stem (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 (NN) or not applicable (NA).
Type of Evaluation
)M Evaluation of on-site sewage system
O Evaluation of drinking water
0 Evaluation of on-site sewage & drinking water
p.2
office Usa only
Date_
Fee
Recpt
clecx ---
case # 7�
Reason for Evaluation
0 Routine Operation and Monitoring Inspection
P1 Real Estate transaction
0 Complete a Permit #
0 Building Permit Review and/or no septic permit on file
0 Other, explain _
Date of evaluations 0 Inspected by %ftob(EftkapheC14
Tax Parcel #06Permitted System _yes -> _no Permiticase # SEP tJ
Subdivision, Division, Block and Lot(s)
Lot Size-.*3�t cr or Dimensions--------X-
Current Owner y,, )=t.=� 100.A%"Z F= -
Site Address ank
Owner Phone # ��
Previous property owner name(s) - (NN if not known) ibn k q-1 ne5. sti'l'l
Directions to Site nr. �: T . �, s-�� w O fi l
Date System Installed_ VS,4 Age of Dwelling \�l� l # Bedrooms !�ZKA
House Occupied X yes no, vacant how long?
Who installed system?
Send completed report to:
Owner
tAAR 2"� roj'l
Name o.� n 'aZ��•J 0un
Mailin Address �'�� �•, 1��-r �T. tri 1UY +`u ®�,9+
9
Phone/emaiUfax�„_
Realtor or Other Representative ^�
Name Camp,
Mailing Address
EES Evaiu8ton Form, 07 -:it:''-
Mar 20 07 11:59a
S -
include the following items on your plot plan:
❑ Property boundaries
• Names of adjacent streets
a Driveways and parking spaces
❑ surface water (ponds,cmaks, etc)
a BuildinW(resldence, sheds, garages. etc)
PLOT PIAN -date
p.3
D Wells
0 Septic tank
C► Drainfield (enter NN if unknown)
a North Arrow
NOT TO SCALE
t"�,N�1e'WCN[V�
Perrrdt # o aM I
Evaluation of an
ENVIRWCf1FCK-LLC.
1612 Hastings Ave. W.
Port Townsend, WA 98368
_07j!3(v0-4-Pdi
f a6 �t1 2 7
Jefferson County
Environmental Health,
gage 2 of 5
Mar 20 07 11:59a
mato of IncnPr lien r)fM Q(n inspected by
p.4
Q* WWWO (Dwkadvok, =)
Water Suaaly (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 des no, if not, distance
ONS1TE SEWAGE SYSTEM
# Bedrooms/gallons per day indicated to County Health Dept records for this case �L�-N --
#1 - Sep
tic Tank
Tank size k i rQ gal- -Xsin9ie compartment two compartment g'45SR gE _ material
Riser to grade on inlet ves__._._ no. Riser to grade on outlet yes �_no
Condition of tank 7( good needs repair, describe
1st comp.'Srurn (trop layer} 2, in. sludge (bottom layer) in.
2nd comp. scum in. sludge in.
Was ground water observed leaking into tank ? des K ._ no
- If yes, where was water observed?
Condition of baffles: Inlet it &IQ needs repair material (PVC. cref
outlet good_,__ -)S ___needs repair material (PVC ncxe )
Screened outlet _, X _no ,yes, condition clean dogged/dirty
Septic tank needs to be pumped (per Jefferson County code 8.15.150 (1) (b)) yes _)L_no
Effluent level at outlet (mark level on circle) if effluent is below the outlet, indicate
when tank was last pumped:
leg: 9) 0
Does system Include a pump? yes If yes, complete the nerd section X— no Of no skip to section 3)
##2 - Pump Chamber
'sank size gal. Material. Riser to grade? ves 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? no Yes,
Shroud around pump? no -------Yes
Electrical Components
Penrd #
condition dean dirty/dogged
Pump operating , ves no, descnbe
High water alarm functions ves no, if no, describe
Elea Panel condition good needs reparc, describe
Pump cycle drawdown inches. Time for pump cycle MWsea
Tuner Settings mm/sec on min1brs off Floats secured: _yes no
Onsite Sewage
Mar 20 07 12:OOp
.M
p.5
#3 — Drainfield
Appropriate Vegetation in area ----Yes no. Describe vegetation
Indications of surfacing sewage (check one) ves , if yes, describe and diagram on plot pian
x no
drainfield area is overgrown and not observable
Signs of parking/driving in area _ - yes no !_ grainfield area unknown
Ground settling or erosion yes no overgrown/not observable
Monitoring Port Observations (if present).
Residual Head as, # of inches no
Ponding in trench ves, # of inches of ponded effluent no
Repair area is? Available as shown on permit None evaluated or shown on permit
Addendum (page 5) is attached for evaluation of Treatment Unit or detailed evaluation of drainfleld
YesY'--no
COMMENTS (attach additional sheet if necessary):
#1-A. Risers are mandatory on next inspection.
$. `VIAV- 14 Ci�1 £O roR�l'tPb
%s a c -,s 41s
441y -
rn.> Abl-I ?d€i"le:-+ of au -SITE 5tLi&6S sYS'iEjr..
other (A) No permit is on file as to size, lace�on or
adequacy and it could not be determined 5�
.� ,�--TN►,ak L�oYr� of-D,.� u�.1ta�-1�iaa 11 . fhQ�2 iTt� l(L
SEE ATTACHED ADDENDUM
a'sts.
Was a System Problem Identified? Yes T X if Yes, what section #. t No
This report on the existing onsite sewage system is valid for the permitted or historic (if installed prior to perrrpt
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 infonnation provided is nn a review of County records and my direct observations at the time of
inspection.-
NamelSignaturse 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 #
onsite Sewage System _fJ'„rGpdf- u tea;_e ? of :.
AR - o
a��sB`�G�G�64 ��N�OiEfl:
Mar 20 07 12:00p
p.6
# 99 X21
DATE eaAPtf�04
ADDRESS—, � �� D, ,► VIRWCHECI, L.L.C.
OWNER, �f ., g. 'aa Port Townsend WA 98368
ADDENAUM
Enviro Check, I t..C. Company Disclaimer
Based on what we were able to observe and our experience with on-site wastewater technology, we 'submit
this Sewage treatment InspecbOWEvaivation Report based on the present condition of the on-site sewage
treamnent system. Enviro Check, L.L.C. has not been retained to warrant, guarantee, or certify the proper
functioning of the system for arty period of time in the present or future. Because of the numerous factors
(fie, soil cha ractatistics, 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 inspectioWevahcntion of the septic system or This iepordevaluation. 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 oil site sewage
systems on to adjacent properties. Any indications of possible property lines/boundaries we approximations
and do not indicate legal property lines or boundaries.
Enviro Check, L.L.C. will not be held responsible in any way for information being undisclosed
(ntentionally or unintentionally) by property owner, representative or other parties of interest.
All reports, including E -SS. inspection reports are subject to any change by Jefferson County
Environmental Health Departmexxt Enviro Check LLC is not liable for any such changes.
All parties are encourages to check county records for any information regarding properties-
Comivany
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
' Jefferson County Ordinances, and to the best of my ability, correct.
Co -Manager
�1VIPLING (Septic bank)
Date -
PH, Result-
DO
esultDO Result
Tenn• Result.
MEASU1tEMEM
CouunRer Settins-
Houir Metar-
Jefferco ➢ CountY