HomeMy WebLinkAboutSEP1974-00024Jefferson County Department of Community Development Office Use on!
6�1 Sheridan St., Port Townsend WA 98368 (360) 379-4450 y
Date
Evaluation of an Existing Onsite Sewage System (EES) Fee
Draw on the back of this sheet a current plot plan showing location of: Recpt
Buildings, Drainfields, Septic Tanks, Wells, etc OR attach a current plot plan Check
identifying these items. Case#_
ALL SPACES MUST BE FILLED IN.
If information is not available enter (NV) or not applicable (NA).
Type of Evaluation Reason for Evaluation
0 Routine Operation and Monitoring Inspection
Evaluation of on-site sewage system Real Estate transaction
0 Evaluation of drinking water 0 Complete a Permit #
Y.. 0 Building Permit Review and/or no septic permit on file
0 Evaluation of on-site sewage & drinking water. 0 Other , explain
Tax Parcel Permitted System dyes no
Subdivision Division, Block and Lot(s) C� ��# " A_
Lot Size_ cres r Dimensions X
Current Owner R,.,-
Site Add
Owner Phone #
Previous property owner name(s) - (NN if not known)��
Directions to Site -
w
Permit/case # SEP
W
Date System Installed l b•—'� Age of Dwelling- <<i"j (p # Bedrooms✓
House Occupied —X—_yeS no, vacant how long?
Who installed system? _!' _ T',�,,�
Send completed report to:
Owner
Name
Mailing Address -1
M
6"
� a
FEB 18 2003 J
J[FFERSGN COU r Ir
"� c O'diMUNII DEVELOPMENT
Realtor or Other Representative
Name %2t , € I DdwV- oe7% o �Zpoz'- a-hA;J
Mailing Address 3a�)b��k ?'L �,�,�--�0 0�� 98348
hon email/fax "j je2=3�S»-
i -
,. , Evaluation of an Existing Onsite Sewage System
Date of Inspection p n 0 03 Inspected by 'D&LE V l�'Stti+"��'� ejp'Uaow)
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—z
#1 - Seatic Tank
Tank size %b00 gal. C single compartment two compartment cAe,�,gi firM material
Riser to grade on inlet vest_ no. Riser to grade on outlet Yesno
Condition of tank ?c good needs repair, describe
1st comp. Scum (top layer) �_in. sludge (bottom layer) 1 in.
2nd comp. scum in. sludge in.
Was ground water observed leaking into tank ? yes X no
If yes, where was water observed?
Condition of baffles: Inlet K d664 needs repair
Outlet: dood> X. needs repair material PV ,concrete)
Screened Outlet _X_no _yes, condition clean clogged/dirty
Septic* tank needs to be pumped (per Jefferson County code 8.15.150 (1) (b)) yes no
Effluent lever at outlet (mark level on circle)
If effluent is below the ouilet, indicate
when tank was last pumped:
( eg: )
Does system include a pump? yes If yes, complete the next section �C _ no (if no skip to section 3)
#2 - Puma 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? j
Screen around pump? yes no Shroud around pump? yes no
Electrical Components
Pump operating ves no, describe
High water alarm functions ves 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 # �E r —AA —C4
Documeml 3 of 4
. 9
Evaluation _of an Existing Onsite Sewage System
#3 — Drainfield
Appropriate Vegetation in area _ _yes no. Describe vegetation C:" R&SG
Indications of surfacing sewage (check one) ves , if yes, describe and diagram on plot plan
�C no
drainfield area is overgrown and not observable
Signs of parking/driving in area ves—no 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 _None evaluated or shown on permit
Addendum is attached for evaluation of Treatment Unit or detailed evaluation of drainfield _ ves—)L—no
COMMENTS (attach additional sheet if necessary):
SEE ATTACHED ADDENDUM
Was a System Problem Identified? Yes if yes, what section #. No_ t c
This report on the existing onsite sewage system is valid4for 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) an 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.
Na e/Sig a 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 Parcei # 'J (� 4. cf•�.'
Documents 4 of 4
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 u
❑ Surface water (ponds,creeks, etc) ❑ North Arr w
❑ Buildings(residence, sheds, garages, etc)
PLOT PLAN
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ZENVIRCWt HECK LLC.
S 1612 Hastings Ave. w
(A;1d a, Port Townsend, WA 98368
Permit # or Parcel
*� 2 of 4
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ADDENDUM
Enviro Check, L.L.C. Company Disclaimer
DAT
ADDRESS 18k w VoI0s1�'
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.
Company
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.
Dale R. Wurtsmith Co -Manager
Weather Conditions S�LAQ
SAMPLING (Septic tank)
Date -
PH Result -
DO Result -
Temp. Result -
MEASUREMENTS
Counter tting-
Hour MeteY-
Water Usd9d (Ave.GPD) Met&
Squirt Height (In feet)-
903 E. Caroline OLYMPIC HEALTH DISTRICT Permit No.
Port Angeles SEWAGE DISPOSAL PERMIT APPLICATION
Submit in Delicate Builder
Court House
Port Townsend Date
OWNER ADDRESS .. fit.-.. , 2 - - PHGM
DIRECTIONS FOR LOCATING SITE
APPLICATION IS HE= MADE T0; INSTALL N34 SYSTEM REPAIR EXISTING SYSTEM
esi eKe
,0®
'
E OF. BUILDING
NT N0. OF BEDROOMS BASEMENT
SITE SIZA
NAME OF: INSTALLER
DRAINFIELD LENGTH 't
SQ WIDTH r DEPTH rLINE i �EPTIC TANK SIZE
DRAW A^DETAILED PLOT PLAN BELOId. SEE INSTRUCTIONS. SOIL TYPE
&)a#
300
tfoo -rf
DATE OF INSTALLATION SIGNATURE OF APPLICANT
APPROVED DATE rZ !�"INSPECTED BYDATE
SANITARIAN'S C01 '1 NTS •
I CERTIFY THAT THIS 8cm `! PT L D I THE MANNER APPROVED BY
HEALTH DEAFRTMENT
[? c. Z&11,4j a-//, -! ®.. d- - e— S, P. A
Jefferson County Department of Community Development (AA (CJGP
621 Sheridan St., Port Townsend WA 98368 (360) 379-4450
MONITORING INSPECTION CERTIFICATION
The system serving /8/ =- efvf * `/V s on
parcel # 1750 1 Oq t �� . permit # X76/ - was most
recently inspected on _ by JdP-- h I . as specified in
Jefferson County Code 8.15.150.
The above referenced system is in compliance with the Monitoringrinspection schedule
Identified in Table 1 of Jefferson County Code 8.15.
F)q- See report completed �/03> for information on the condition of the
onsite y
sewage system.
F
REQUIRED OR RECOMMENDED REPAIRSIMODIFICATIONS 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 or future system performance.
HOME,,;,
Signature of J
Employee
If: em•_healthUindal(7D\FORMS\MONITORING INSPECTION CERTIFICATION.doc
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REPORT To PARMS
OLY101C HEALTH DISTRICT
Nam trade Date
Address Teacher
Results..of eye screening by the public health nurse indicates that your child
should, be seen by, an eye sPecialist for complete examination.
VISION: R. L
Observed symptoms:
Other eye symptomst
If there is any question in regard to this you may call me at:
Public Health -Nurse
Please take this form to the doctor
.. - - - - - - - - - - - - - - - - - - - - - - r. _ - - - - -
DOCTOR'S REPORT TO SCHOOL
GLASSES:
None needed.
To be worn
Other'
Best'correction to be expected by glasses: R: L:
Suggestion as to'specific needs for childfs school program (special equip.jetc
Date
• Doatorls Signature
NOTE TO PLEASE RETURN THIS REPORT TO TIM, SCHOOL so it can be made a
PARENT: permanent part of the child's school health record for quidanee'
of the health department and classroom teachers.
g-62
,
t : f:(f �'e t,. `j m'ji au°i'e� z oi�g fide : of t .Fine r
of ;Goverrjment Lot i ; eeti.dn Q , TownObip �$'. nortbr Range
JL West' W.M, in J of f e ton County ► Wa ngtan, .;
`h�`:F'T m�ITE RnM the So th, 993 ..00 feed, 4s.:�AeaQtre
along the Wes=t: I i_R; thereof.
i
SND EXON- TTtHEn-FROMplbIio road .
`
TOGETI R WITH AND SUBJEOT '0 an easement, fpr purFoseS
ingress, egress,drainage 'arid utility es evert' un er,
t:
and acnose:.the South bO..OQ::fee.t of `;tie 'tart 32.®a deet,
all as measured alongg..;th West ;1ine;,
the N.; E. �f said Section 4; r
.. t o
Ali air 'e Ea .t 6 0' 0 0 a
the N . (?. O.f'oet o% the West 7 7,5 Feet.:
9
ured: a the.,Narth.
as zea ong Iinei. jbf
e
the 4. E.`
ANI)j 'the :fast ` 4.bD feet of the West 707.
as measured along the South lin* e of: said Govern?�ent dot
'
1 , EXCEPT ' 'HER.EFROM the No 'th a :2 9 :2 5 fe t ` hereoi'
A� �r the Sdu�ih6D:"00 feet �6f the North 32 .'00 flet all :
as moasureo along `tb Fast n.e, pf' A,the East '6? '.5 ..feet`,
`tl
as measures .along the`: North litre, of the a �: W. o et
N: E..,, of:. said Sects Qn
i tri ' w > t 6o.QOz4egt of .`the as ` 74,x. a fey
,ae. measure along th.e'Nort)i Iine, of sa�� S,«
AND 'ths.:We t. tJ.QO- feet of -the `East` 767, 5A eetr a�
as measured a(l`] ong the. SoutY life,.. o fiQ4ernment
t
.. •R. Cls' V�'�at �1r'a,. T .
3
AND EXCEPT'':y�HEREFRON public" roads. f
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SITE EVALUATION RECO13D
TO:
OLYMPIC HEALTH DISTRICT
Seo`` 5 4 T%m, 28 Ni R. I W
Legal Description
2'.._intot J-01: I- V,4'�ey
Site Size —5 acres
Buyer
-i -.. -or on
A site eviLluation of tYie above property his been made by.this department and your
request for residence
has been (approved)
Comments:
"'bc cryed two -,;C.41 Lo,,., 11=,Ios 4 fte
d-een- �—e�-wao lZaimd to be and loam faix for
-JOLIIC 1�3?-
:-i7ie, lrA,,rfield tent-qtive plini bc�;Ii
Very truly yours,
Sanitarian
Date:
CC: Ere Kenry 71amuss 1•44icott Realtyq k,ort lo,.msend
OHD: 11/73
Jefferson County Health Department Receipt No.
802 Sheridan Ave.
Port Townsend, WA 98368 Fee: r S
206-385-0722
° Date:_
EVALUATION Qin' INDIVIDUAL SEWAGE DISPOSAL SYSM AND/OR MATER SUPPLY
Information Requested: x__ Individual Sewage Disposal System
x Water Supply x Public Private
APP1ic;-MtS Nam Nancy S t e f f e /J - Mail Completed Report To:
N
Address ancy S. Steffen Owner
Rd.
him num, WA 9832
Phone: 732-4274 Number of bedrooms 3
Previous Owner (if Known) none Year Installed 1976
Legal Description: Section 4 Township -2B Range 1W
Street Address 191 W I;gg & I R Chimacum WA 98325
Directions to property 1000 ft West of West Mallen Rd. oh Eam & I Rd
SEWAGE DISPOSAL
Permitted system yes no .
Installed prior to permit requirement yes ✓ no
Sewage noted on ground at time of insertion* _ yes ✓ no C �j1
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 bedroom residence. This spstem is not considered
adequate for a bedroom residen<* unless it is sized per current
regulations-
-Septic tank should be pimped if not done within past 3 - 5 years. -
WATER SUPPLY
Well using 12" above ground ✓ yes _ no
Sanitary seal in place yes no
Well 100' from drainfield ✓ yes ! no
Water sample taken yes no tl-z9-tea.
Sample results
ctmnents: r;, T7o
5eivti c adv —7 L.'S 3 + z $ LI� ck 6,- P40' V'zr A -AI -a 7"-� d�i-� !� � e 4G�"�
j-=n� lac, -Ccs) e%-7 Lot Z ko.4d hr- rZpL-,c-Cd.
04, s3-fFe. y eG ►lob a �R. -!� Kt f-�� oo A) -
Date !1-Z�-S�/. Time z:3e P*" Ow , ��lcis�i�ti
Environmental Health %-ecialist
* This report does not constitute a guarantee, either written or implied, that
the system will continue to function properly. This report constitutes a
summary of findings only.
EESFORM 11/88 1 C� �:
JEFFERSON COUNTY BUILDING APPLICATION
Jefferson County Permit Center
Castle Hill Mall
621 Sheridan St.
Port Townsend, WA 98368
360-379-4450
PERMIT #....:BLD96-0374
SITE ADDRESS:181 W EGG & I RD,
:CHIMACUM, WA 98325
DATE RECEIVED.:06/20/96
-------------------------------------------------------------------------------
APPLICANT...:NANCY STEFFEY PHONE:360-732-4210
MAILING ADDR:181 W EGG & I RD/
:CHIMACUM WA 98325
-------------------------------------------------------------------------------
CONTRACTOR..:OWNER PHONE:
MAILING ADDR:
CONTR. LIC #: EXPIRATION DATE:
ARCHITECT/..: PHONE:
DESIGNER....:
MAILING ADDR:
PARCEL NO ... :801041027 ALT : CON
LEGAL DESC..:STR 04-28-01/ WWM, TAX # 211 BY :DATE: CaaS-qCo
LOT 2, BLOCK , CANARY LANDING S P P1 V
(,
WATER: DATE:
DESCRIPTION OF IMPROVEMENT:
de�k
--------------------------
BUILDING TYPE ...... :RES
-----------------------------------------------
BEDROOMS---
BATHROOMS--
MAIN FL...:
0 sf
TYPE OF IMPROVEMENT:ADD
EXIST.: 0
EXIST.: 0
ADDIL FL..:
0 sf
GARAGE/CARPORT.....:
PROP..: 0
PROP..: 0
HTED BSMT.:
0 sf
WOODSTOVE.......... :
TOTAL.: 0
TOTAL.: 0
UNHT BSMT.:
0 sf
UBC OCCUPANCY GROUP:
SEWAGE DISP..:CON
OTHER.....:
0 sf
60�,
TYPE OF CONST......: n7
WATER SUPPLY.:
CRPT/GAR..:
0 sf
UNITS.: 0 STORIES:O "'
HEAT TYPES.:
DECKS.....:
90 sf
DIMENSIONS:
-------MOBILE HOME------
COMMERCIAL:
0 sf
FRAME TYPE:WOOD
MAKE:
YR:
INDUSTRIAL:
0 sf
EST COST.$: 900
SIZE:
BANK HT...:
0 ft
PROD GRP..: 8097
SH SETBACK:
0 ft
------------------------------------------------------------------------------
Owner/agent
----------------
FEES --------------
Signature:
type amount
by date
recpt
PRMT $ 34.75
JM 06/20/96
1122367
Date:
PLCK $ 10.43
JM 06/20/96
1122367
B.C. $ 4.50
JM 06/20/96
1122367
Issued By:
Date:
------------------------------------
49.68 TOTAL
t I
WEST EGG AND I ROAD
I DRIVEWAY
WATERLINE AND
EASEMENT
EXISTIN
co
r
72 ft
0
EXISTING M
BUILDING COMMUNITY
WELL
SETBACK
AREA I
PROPOSED DECK/EXISTING SEPTIC
AND DRAINFIELD
EXISTING
SHED
PROPERTY BOUNDARIES
210 ft
DECK ADDITION SCALE: One inch equals forty feet
CANARY LANDING LOT 2
JUNE 1996
Parcel Details
.11� i�
Parcel Number: 801041027 SEARCH
Parcel Number: 801041027
Owner Mailing Address:
DAVID BEATIY
PO BOX 184
PORT HADLOCK WA983390184
Site Address:
181 EGG & I RD
CHIMACUM 98325
Printer Friendly
Section: 4 School District: Chimacum (49)
Qtr Section: NEI/4 FreDist: Chimacum (1)
Township: 28N Tax Status: Taxable
Range: 1W Tax Code: 211
Planning area: South Chimacum/Inland Valleys/Center (6)
Sub Division: CANARY LANDING SHORT PLAT
Assessor's Land Use Code: 1100 - HOUSES (single units, non-farm)
Property Description:
CANARY LANDING SHORT PLAT I LOT 2 1 1 1
Click on photo for larger image.
No Permit Data Availables r Da ax HIAW LMap Parcel JPlats& Sunteyss
Page 1 of 2
http://www.co jefferson.wa.uslassessors/parcel/parceldetaii.asp?PARCEL N0=801041027 2/10/03
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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.
oning information is based on the 1998 Comprehensive Plan Map and does not include changes made
unng the 1999 Comprehensive Plan amendment process. Zoning designations must be confirmed with the
De rtment of Community Development
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