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Home My WebLink AboutBLD2015-00055 - 01 PERMIT APPLICATION 2s`'`' DEPARTMENT OF COMMUNITY DEVELOPMENT ?� 621 Sheridan Street,Port Townsend,W.-1 98368 Tel:360.379.4450 I Fax:360.379.4451 Web:www.co.jefferson.wa.us/communitydevelopment �S��j �` �� E-mail. dcd(n?co.iefferson.wa.us CERTIFICATE OF OCCUPANCY PERMIT #: BLD15-00055 APPLICANT: PEGGY KLAMKE PHONE: 208-553-2241 P.O. BOX 2663 325 NE PARK STREET POULSBO WA 98370 SITE ADDRESS: 151 DIETZ DR Issue Date: 04/2/2015 QUILCENE, 98376 Final Date: 5/20/2015 SUBDIVISION: Block: Lot: PARCEL NUMBER: 501031008 Section: 3 Township: 25 N Range: 1W PROJECT DESCRIPTION: BUILDING PERMIT FOR EXISITNG MANUFACTURE HOME - SEF'OS-00108 TITLEtLIMINATIuN PROCESSED 6.z015 THE PROJECT LISTED ABOVE COMPLIES WITH THE REQUIREMENT OF THE BUILDING CODE 2012 EDITION. OCCUPANCY GROUP: TYPE OF CONSTRUCTION: 0-SPRINKLER SYSTEM yes THE PROJECT PASSED ITS FINAL INSPECTION AND RECEIVED FINAL SIGN OFF ON 5/20/2015 \\tidemark\data\forms\F_BLD_Occu pa ncy.rpt 6/19/2015 BUILDING PERMIT Jefferson County Department of Community Development 621 Sheridan Street, Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 PERMIT #: BLD15-00055 Received Date: 2/25/2015 SITE ADDRESS: 151 DIETZ DR Issue Date 4/2/2015 QUILCENE, 98376 Expiration Date 4/2/2016 OWNER: PEGGY KLAMKE PHONE: 208-553-2241 P.O. BOX 2663 325 NE PARK STREET POULSBO WA 98370 SUBDIVISION: Block: Lot: PARCEL NUMBER: 501031008 Section: 3 Township: 25 N Range: 1V CONTRACTOR: PHONE: PHONE: PROJECT DESCRIPTION: BUILDING PERMIT FOR EXISITNG MANUFACTURE HOME - SEP05-00108 TYPE OF WORK MOB SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: VALUATION ADD'L: HEAT TYPE: EEE CODE EDITION: 2012 HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: #OF STORIES: OCCUPANCY: OTHER: CONST TYPE: GARAGE: SHORELINE: CONST TYPE: DECK: SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: 1PWELL Type Amount Paid By: Date: Receipt: BEDROOMS: BATHROOMS: Permit $156.00 SRE 02/24/15 154128 Exist: 0 Exist: State Building Code $4.50 SRE 02/24/15 154128 Prop: 2 Prop: 2 Potable Water Application $68.00 SRE 04/02/15 154313 Total: 2 Total: 2 Total: $228.50 Directions to Site: HEALTH DEPARTMENT AND PUBLIC WORKS APPROVAL REQUIRED PRIOR TO FINAL INSPECTION THIS PERMIT IS VALID FOR ONE YEAR OR IT MUST BE PROPERLY RENEWED BUILDING INSPECTION HOT-LINE 379-4455. Request must be received by 3pm the day before the inspection is needed. Office Hours 9:00 am - 4:30 pm MONDAY- THURSDAY HOT LINE AVAILABLE 24 HOURS A DAY • 0 Jefferson County Building Division Permit Number: BLD15-00055 Applicant: KLAMKE BUILDING PERMIT INSPECTION APPROVALS Applicable Code: 2012 International Building Codes To schedule inspections, call (360)379-4455 no later than 3:00PM the day before the inspection is needed. Requests received after 3:00 PM will not be scheduled for the next day's inspections. ELECTRICAL PERMITS are issued by the Washington State Department of Labor& Industries. The electrical permit must be signed off by the State Inspector prior to the County's Framing Inspection Inspection Item Date Approval Signature Notes Septic System Finaled cp05-00108 46/Oek Vie- -y Ok S/2-61ts Vriekkewe CGeoKNv eav e) OK _OA/ts ✓ )-rr 5 OK S/7rlis O ' 37-aPs 144497_A/ c i 4ROpA/IS 4k /z s"7 /g ,(E.o G',oe Parr cua. h WC 5/21/1,1-5/21/1,1- (I 6 X/ A final inspection will not be scheduled until the following are completed and signed off by the applicable Department: • Building Permit Conditions are met • Septic Permit Final/Complete for any building containing plumbing • Land Use Conditions met and signed off • Public Works Permit Final(where applicable) FINAL INSPECTION , /4l5 FINAL INSPECT! MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED THIS PERMIT IS VALID FOR ONE YEAR • • 471AI 2_4_1 - P Lc cc& c,r44cLvv -�-� 4.. _ t •UILDING PERMIT APPLICA Tlits1 BLDI5-00055 Review Type: Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD15-00055 Received Date: 2/25/2015 SITE ADDRESS: 151 DIETZ DR QUILCENE, 98376 OWNER: PEGGY KLAMKE PHONE: 208-553-2241 P.O. BOX 2663 325 NE PARK STREET POULSBO WA 98370 SUBDIVISION: Block: Lot: PARCEL NUMBER: 501031008 Section: 3 Township: 25 N Range: 1V1 CONTRACTOR: PHONE: PHONE: REPRESENTATIVE: PHONE: PROJECT DESCRIPTIOP BUILDING PERMIT FOR EXISITNG MANUFACTURE HOME - TYPE OF WORK MOB SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: VALUATION CODE EDITION: 2012 ADD'L: HEAT TYPE: EEE OCCUPANCY: HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: #OF STORIES: OTHER: CONST TYPE: GARAGE: SHORELINE: CONST TYPE: DECK: SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: BEDROOMS: BATHROOMS: Exist: 0 Exist: Prop: 2 Prop: 2 Total: 2 Total: 2 Routing Date: Type Amount Paid By: Date: Receipt: Approved/Date Permit $156.00 SRE 02/24/15 154128 `, State Building Code $4.50 SRE 02/24/15 154128 APPR® tl Et) Total: $160.50 APR - 2 2015 Jefferson County DCC 1\tidemark\data\forms\F_BLD_App_Bld.rpt 2/25/2015 Parcel Details Page 1 of 2 jiliTh' Jefferson County , :,,,,, ,...., ---,...----- -t--:i7-,,....L..,, ,---z :_.-__. ,..„_-_, ._.,ffi.:Aw---774.i.--- "V:471.-7.70-i-:, L ,„,...„,-- Home County Info Departments Search Parcel Number: 501031008 SEARCH Parcel Number: 501031008 Printer Friendly Owner Mailing Address: IRVING J KLAMKE PTA poc - (,CPEGGY I KLAMKE 325 NE PARK STREET POULSBO WA98370 t `S I6 LA Site Address: � LS - Ss-- 151 DIETZ DR QUILCENE 98376 Section: 3 School District: Quilcene (48) Qtr Section: NE1/4 Fire Dist: Quilcene (2) Township: 25N Tax Status: Taxable Range: 1W Tax Code: 0323 Planning area: South Toandos Peninsula,Coyle Area (9) Sewer: Drainage: Bank: View 1:VIEW Territorial View (t l WA e ri View 2: Zoning 1: I� Zoning 2: jq • 1 Sub Division: I 3 uoout d Ieel Assessor's Lar 3nd \CNA1dln rf,,..� K/a1n ?2 47 v °� Property De: ✓� 12e " (�e�i149- A-�1e, S3 T25 R1W 1 �� 16988 Permit C 2 1/ / Plats &Surveys Septic Monitc PS r 3- O) ' C 3I — 0V 3 I DEPARTMENTS I SEARCH de f Best viewed with Microsoft Internet Explorer 6.0 or later , c 2 I,rs lhSped �`COrl/ Pthf-tt'Lf f ec 6 Windows - Mac Sly eo Ei 4 _ 1 qr 1 r �� E`-t ,-, A rIB_ http://www.co.jefferson.wa.us/assessors/parcel/parceldetail.asp?Parcel N-501031008 2/17/2015 • Cases Associated with a Parcel Page 1 of 2 iefferson Count Weather Station Database TnOVI._ - •aps,.-;-' -'iMe1carii'.` Home County Info Departments Search Cases Associated with Parcel No: 501031008 This may not be a complete listing of information that exists for this parcel. There may be other information pertinent to the property on file. Please contact the Department of Community Development for additional information. To view the scanned documents from the case file's listed below click DCD CASE FILES and go to the year listed on your permit number to view the documents. Case Number BLD89-00130 Description CREATE CASE FOR OLD FILE - MOVE M/H FROM RENTON, WA TO THIS PARCEL INSTALLED 1964 10X40 Last Name MABLE Received Date 11/5/2014 10:35:35 AM No Images Case Number CAM14-00572 Description Restriction on property for building Last Name CRANBACH Received Date 10/21/2014 12:11:22 PM No Images Case Number SEP05-00108 Description info from SEP90-567 filed here. 1 f1Cc-'`rT�E"� Last Name KLAMKE Received Date 4/14/2005 Images Case Number SEP90-00567 Description info filed to SEP05-108. EES only record, no permit on file Last Name KLAMKE Received Date 1/10/1990 Images Case Number SOM90-00567 Description Last Name KLAMKE Received Date http://www.co.jefferson.wa.us/commdevelopment/ppquery/cm.asp?value=501031008 2/17/2015 2/20/2015 Shod Excavating Inc. PO Box 179 360-385-0480 Port Hadlock, WA 98339 PROPERTY INFORMATION Location:151 DIETZ DR Tax ID:501031008 Mall To: IRVING&PEGGY KLAMKE 151 DIETZ DR Use: OUILCENE,WA 983769600 Owner:IRVING&PEGGY KLAMKE ON ID:SOM90-00567 Fold r ON-SITE WASTEWATER TREATMENT SYSTEM INSPECTION REPORT Fold Here Here Inspected:01/07/2015 - Inspection Type:FOLLOW UP - Correction Status:No corrections made Company: Certification-Level 2 Work Performed By: Submitted 01/08/2015 by: Shold Excavating Inc. Timothy Johnson Timothy Johnson This report does not assure approvals by Jefferson County Public Health for ANY future building permits or development. COMMENTS & GENERAL INSPECTION NOTES Deficiencies Noted:defici. cies must be corrected to ensure proper longevity of the Onsite Sewage System. The septic system[sep05-1081 is in an incomplete status. GENERAL SITE&SYSTEM CONDITIONS The General Site and System Conditions were: Partially Inspiected All Components accessible for maintenance,secure and in good condition: Surfacing effluent from any component(including mound seepage): Components appear to be watertight-no visual leaks: Improper encroachment(roads,buildings,etc.)onto component(s): Component settling problems observed: Abnormal ponding present for one or more of the disposal components: Subsurface components adequately covered Owner compliance issues noted Site maintenance required(e.g.Landscape maintenance)If yes,describe in comments: Occupant compliance problem(occupant not operating the system properly). If YES,describe in notes: If deficiencies were identified on last inspection were they corrected before or during this inspection? (If NO,describe in notes,NA=no deficiencies on last report): OSS Components,structures and appurtenances located per as-built/record drawing(If NO,describe in notes). If no as-built exists or changes made,state NO and provide record to Health Dept: Alterations made to the OSS(valves adjusted,timer settings modified,ports installed,etc.)(If YES, describe in notes): The house/structure was vacant or used infrequently,assessment of the drainfield was not possible. Is the SEP case in a finaled/completed status?(if NO explain in comments) NO-Deficient • ONSITE SEWAGE SYSTEM INSPECTION DETAIL ANK:Septic Tank-2 Compartment This component was: Not Inspected Component appears to be functioning as intended. Effluent level within operational limits(if NO explain in comments): All required baffles in place(N/A=No baffles required): Effluent Filter Cleaned(N/A=Not Present): Compartment 1 Scum accumulation(Inches,if other specify): Effluent filter/screen needed cleaning on arrival Compartment 1 Sludge accumulation(Inches,if other specify): Compartment 2 Scum accumulation(Inches,if other specify): Compartment 2 Sludge accumulation(Inches,if other specify): Pumping needed: Approximate Gallons to be pumped(if needed)by Certified Pumper: ReportiD:416307 View inspection reports online at www.onlinerme.com Page 1 of 2 Distribution:D-Box This component wa i Not Inspected D-B ox in good condition: D-Box outlets set to allow equal effluent distribution: Drainfield:Gravity This component was: Not Inspected Component appears to be functioning as intended: Ponding present?If YES explain in comments: This report indicates certain characteristics of the onsite sewage system at the time of visit.In no way is this report a guarantee of operation or future performance. ReportiD:418307 View inspection reports online at www.onlinerme.com Page 2 of 2 kjWashington State Department of Factory Assembled Structures Labor & Industries Correction Report Factory Assembled Structures The corrections listed below are hereby ordered and must be completed within 20 days of issuance. Contractor/Owner Date of Inspection Permit Number KLAMKE, PEGGIE 2/4/2015 FP2475079 Address of Inspection City 151 DIETZ DRIVE QUILCENE NOT APPROVED FOR COVER NOT APPROVED FOR SERVICE Is the permit fee correct Li Yes Li No Fee due$ $0.00 Correction(s)issued on: 2/4/2015 Li 2013 HRI APA.AIt(APPROVED ALTERATION(S))Approved alteration(s) Correction Issued on: 2/4/2015 by Glasspoole, Brian The following has been inspected, approved and meets the requirements of the Department of Labor and Industries Decertification of mobile home DOH#81660 SPA dg, Inspector Glasspoole, Brian . (360)415-4026 Inspection Request Line (360)415-4039 Page 1 of 1 0 Washington State Department of Factory Assembled Structures Labor & Industries Correction Report Factory Assembled Structures The corrections listed below are hereby ordered and must be completed within 20 days of issuance. Contractor/Owner Date of Inspection Permit Number KLAMKE. PEGGIE 2/4/2015 FP2475079 Address of Inspection City 151 DIETZ DRIVE QUILCENE NOT APPROVED FOR COVER NOT APPROVED FOR SERVICE Is the permit fee correct I� Yes No Fee due$ $0.00 Correction(s) issued on: 2/4/2015 ��::11 2013 HRI APA.AIt(APPROVED ALTERATION(S))Approved alteration(s) Correction Issued on: 2/4/2015 by Glasspoole, Brian The following has been inspected, approved and meets the requirements of the Department of Labor and Industries Decertification of mobile home DOH#81660 C 5 - toy Inspector Glasspoole, Brian (360)415-4026 Inspection Request Line (360)415-4039 Page 1 of 1 ��SON co DEPARTMENT OF COMMUNITY DEVELOPMENT W �� 621 Sheridan Street,Port Townsend,WA 98368 r-, Tel:360.379.4450 Fax:360.379.4451 ";. Web:w\nv.co.jefferson.wa.us/communirn_development , , E-mail: dcd(alco.jefferson_wa.us PERMIT FEES WORKSHEET Name Peggy Klamke Parcel # 501-031-008 Estimated Cost of Project Permit# Building Base Fees Building Base $156.00 Plan Check Review Land Use Review Septic Review $80.00 Potable Water Technology/Scan $19.50 State Fee $4.50 Other Fees Shoreline Exemption Zoning Zoning New Address Public Works Total Fees $260.00 Office Use Only Receipt Number: t 2-?1 Cash/Check/CC: I 7 Date: ,.1/d-L-1 f 1 L ON DEPARTMENT OF COMMUNITY W DEVELOPMENT <Q, G is co 621 Sheridan trees,Pmt Townsend, A 9N3b$ k, Tel:3(0.370.4450 I Fax:3(10379.4.451 ti -4. Web:www.co jefferson.wa.us/cotmmuutydevelopment E-mail:dcdSSco.iefferson.wa.us -1S/1.1'N° s SUPPLEMENTAL APPLICATION DETERMINATION OF ADEQUATE POTABLE WATER CO Owner Name: Pell � 1Q 4vv` Parcel No. `1 J) Q�1 $�' on CL la Site Address: I t f (� L-'-1-z b r,`11 e �!f t. c z f�e u . 9 ?p to A.- Water Source Existing Proposed Attach Copies of: tt 1) Well Logs Private well (if no log report on file,a 1 hr stabilization test may be substituted.) 2) Lab analysis tested within 3 years of application. -Total Coliform,Nitrate-N, Chloride 2-Party Well Items above AND recorded Operations&Maintenance agreement and recorded Easement. 5 Alternative Provide justification and design per Jefferson County System: Environmental Health policy 97-01 Lit www.leffersoneountypubiichealth.org/pdf/Policy_97-01 Raimvater_ ollection.pdf t Valid Water Right Generally applies to springs,attach copy. krt Permit: Public Water: Name of Water Provider: -Submit Water Availability Notification form completed by your water purveyor. NOTE: If any of the above utilities need to be installed and disturbance will occur in a public maintained or unmaintained County road and/or Right-of-Way easement,then a Right-of-Way application will be needed. Resolution 1199-90 requires building permit applications to provide evidence of an adequate potable water supply per the conditions of RCW 19.27.097 and the Guidelines for Determining Water Availability for New Buildings. By signing this application form,the owner/agent attests that the information provided herein,and in any attachments, is true and correct to the best of his, her or its knowledge. Any material falsehood or any omission of a material fact made by the owner/agent with respect to this application packet may result in making any issued permit null and void. I further agree to that all activities I intend to undertake or complete associated with this application will be pe rmed in compliance with all applicable federal,state and county laws and regulations and I 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. Applicant may request notice of the County's Intent to enter upon the property for visits related to this application and subsequent peit issuance. +y+ ,,DD Signature: `� _X ;� ✓O Print Name: P etc) ki K.,YSt..e_ Date: —I- -NS Civil 1 1 FOR OFFICE USE ONLY 1) Water Right Permit It 3)Individual Well 2)Public Water Supply WS ID31 Meets Water Quality Standards? Yes No In Compliance Yes No WRIA 17 Subbasin SIPZ-Coastal/Moderate/High Yes No Based upon information provided by the applicant,it appears that the potable water supply: Meets Conditionally Meets Does not- � ' r= ( - C \ I - lE PEP -'N COUNTY , �_ DEPT_OF Col.: :,i liiTY DEVELOPMENT Policy No. A 92239 GRUNDFOS Customer Name l A ,V I NCB T Pty KLAM t<E i 5 Year Performance Address 151 DIeT2. D . rip-, . City QuILCDVE State WA. ZipC16 `76 . 4. Grundfos Dealer Name Pr.ti `'t tLmv' `t' WATER 7T Address Pe, Box tl m V through 11/2 HP Submersible Pump City PAT 44-Abloc 14 State ',,VA. - Zip 9833q Protection Application Dear Grundfos Dealer: Pump Model: Serial Number: To make certain your customer's Grundfos submersible pump is fully I S 50E15 C-290 940080 289 covered under the supplemental Performance PLUS protection program, Phase &Volts: Horsepower: READ AND FOLLOW THESE INSTRUCTIONS CAREFULLY. Please 1 OP 2' O V I Yz_ type or print clearly. — — - ____ Complete this policy application in Date Installed: Application: full. Then sign and date the application. I+7/I f/05 R {D�lrlAL- Your customer should keep the top white copy of the application. Keep the yellow copy for your records and send Pumping Water Level: Pump Setting: the two remaining copies (pink and 2(o3 2.7`11 goldenrod) to your Grundfos distributor. Should the pump fail due to any of --the conditions specified under Well Inside Diameter: Depth: Performance PLUS prior to the ,fl �SZ' expiration of the 5-year term of the policy, your customer should contact -- Lightning Arrestor Type: you. You then pull the pump and Flow(GPM): g 9 yP : determine if the cause of failure is (z within the terms of the Performance PLUS policy. If it is, Grundfos will New installation or Brand of Pump Replaced. repair or replace the pump at no r�New Installation charge through your distributor. LDS Performance PLUS does not cover _J the labor charges involved in pulling and reinstalling the pump. The Performance PLUS protection policy covers all Grundfos domestic submersible pumps up through 1T12 I certify that a proper lightning arrestor has been installed with this HP. It is limited to the original owner of Grundfos submersible, and that the unit has been installed in accor- the pump and is non-transferable. dance with the Grundfos Installation and Operating Instructions. 1 EE 0 1 � V � -� Dealer Signature: Date, Sul 6r��5 iJuvsi.007 1 9182 1 PRINTED IN U.S.A. MAR 2 5 CUSTOMER COPY lI s J . JEFFERSON COUNTY 1�_ItLPT.OF COMMUNITY DEVELOPMENT . . ...--• ' • ' Fils-Originarand First Copy with ; Department of Ecology WATER WELL REPORT Application Igo. Second Copy--Ovmer's copy S(-1:--- 0/ //14.4-wA••• Third Coos,-Driller's Copy STATE OF WASHINGTON Pertnit No. • -- - (1) OWNER: Neme...2.1J.Y!),:!...-5..0...............____......__...........____ Aactreeedir92.671 er 6'2, c.:"../e--.<:-:...icc /1/4..L............. ---- (2) LOCATION OF WELL colly --). 4.5....74.74,-770/..;CAL_ — -5.1AL1/4 -s GO v. Sec.--: -T'---- .i._N..R./...:i.V.W.M. Searing and distance from section or subdivision corner . 1 (3) PROPOSED USE: Dorneenc/v(!ndostrta: 0 Municipal Ej (10) WELL LOG: Irrigation 0 'rest Well 0 Other D Formation:Describe by color,character,size of material and structure,and show thickness of aquifers and the kind and nature of the material in each stratum penetrated, with at least one entry for each chanpe of formation. (4) TYPE OF WORK: Owner's(X MOse‘1111annthoer of well one) MATERIAL FROM TO New well ) Method: Dug• 0 Bored 0 Deepened 0 CableX Driven 0 73/2•01 i /2.C.47— 6 Reconditioned 0 Rotary 0 Jotted 0 A1 Ahll2 Vern/ / 7 -13-1AL---52/21-0_ 1,v/e4T-Alz<I / ,,-- -7 ‘..... , (5) DIMENSIONS: Diameter of well (4.;?...;;_...._„ inches. /,/ a-'47.. 64-1 erfru,S(.... 2 c" ..24., Drilled 2...4.)-- ft. Depth of completed well....Z...t.1.-__ft. -Rt..14-- ...ref.....A1 (6) CONSTRUCTION DETAILS: 72a41, h..-oio7-e,#),6-21-r1 -7/-, Casing installed: 6, - imam, from .....0....ft, to ..2. 5 2.-tt, • 311.42• S•47119 r.L..65•11 V6• 41/4° 2... "2.- — Threaded Elj, ...........-." Diam. from ...--.--ft. to --......-ft. Welded .....-...--.." Diem, from - ft. to . ft. Perforations: Yes 0 No) .. Type of perforator used - .. perforations from ..-.- ft to ft perforations from ft to ft 0 es-4---------"--•-•-------r\Ln /--. perforations from . -.....-- ft. to ft --Screens: yes cj No' ' /or • Manufacturer's Name / . 1 ii‘4 1 Type .. Model No - I. -N .. ••—•— • Diem. Slot size from ft to ft i- .2217 Diem. Slot size from ft. to ---it ---______ - k"----,. D • , Eir Gravel 7111•11/11/111 Gravel packed: yes a sre'mr.:: Size of ' /NM ivi7".111,Iwo ,On, ' fPZVI. Surface seal: Yes . NOD To what depth? ....I.Y........... ft. -.., Material used in seal-.....i-i-er-...,./Ztlit rs..-..-. '- Did any strata contain unusable water? Yes 0 No 0 (7) PUMP: Manufacturer's Name. RECEIVE r: . HY.. . ____ (8) WATER LEVELS: rgtvi ;sffefaaesgezix.... .................. _It ---AN-2-1-289 Static level Z:601.3....._........_ft. below top of well Date /./..:‘.....4. Artesian pressure . .-........ lbs per square inch Date --1EF1-. COUNT/ __ Artesian water is controlled by.........-.--i,... .. .. .....-............. IftALIH DEFT f& i■iiive:;tc.i (;,) WELL TESTS: Drawdown is amount water level is lowered below static level Work stsuted---22.------,19_ ..2 Completed / , 19.1....... VIts a pump test made'? Yes 0 Nos(;‹If yes,by whom? •• Yieid: gal./min.with ft. drawdown after hrsWELL DRILLF-R'S STATEMENT: - " • " This well was drilled under my jurisdiction and this report is true to the best of my knowledge and belief. --------- Recovtry data (time taken as zero when pump turned off) (water level measured rom well top to water level) NAME ni9(''' spi_S tuz./1 0:=7, //,, ':,- . , ' / `-' Time Water Level Time Water Level Time Water Level (P••son,Arm,or corporation) (Type or print) ,t---. .--, Address.........-..4f......,.A!!..-..:;.(.1)../..YA / 'L - v4:44' ' -'-' ;A:1 Date of test [Signed], - ----- ...:../'l `. - . li,,.. , Bailer test....1..,..:.......gal./mIn. with '--/ ft. drawdown after 1:-/ .hrs. (Well Driller) Artesian flow........... 'rpm Date --- , . i Temperature of water Was a chemical analysis made? Yes 0 No 0-'• License No Date , 19 (bar ADDITIONAL SEIF-ETS IF NECESSARY) EC', 050.1-Po 4150.3 26276 Twelve Trees Lane,Suite C AA Twl S S Poulsbo,WA 98370 LABORATORIES (360)779-5141 _ COLIFORM BACTERIA ANALYSIS Time Sample r,County Date Sample Collected -r Collected � -�f 5*!*=+^;.ter, h / 70 gat'/Y / b Month Day Yea Type of Water System(check only one box) ❑Group A ❑Group B 1 Other Group A and Group 0 Systems-Provide from Water Facilities Inventory(WFI): ID# _— — — — — System Name: Contact Person: J Z?'r -" fir 4"' Day Phone:( ) Cell Phone:(2 , rfF- , zy/ Eve.Phone:( ) FAX:( ) ' Email Address: Sen uns to:(Print Iuli name,: teas and tip co=: .A ii t t qc> 7O SAMPLE INFORMATION Sample collected by(name): Yr> Specific llocatioon where,ssam,sample cone ->!: Special instructions or comments: f /7/ .Li,' 1G 1 Type of Sample(must check only one box of#1 through#4 listed below) 1.❑Routine Distribution Sample 2.Repeat Sample(alter unsatisfactory routine) Chlorinated.Yes No ❑Distribution System Chlorine Residual:Total Free _ 0 Source Groundwater oRle ule(GWR) 3.Raw Water Source Sample Unsatisfactory routine lab number E coil-GWR source sample ti ❑Fecal-Surface,GWI,some springs Unsatisfactory routine collect date ❑Other f S , Yes No - PubicsyslaYentelpowlesthecenumbe tan WFI t - -- Chlorine ResMUaf Total� _Free_ DECERvie 4:,,Sample Collected for loP oatiOfl Only may} Investigative Construction i Repairs— Private Residence_L2__ Other__ LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ' Lt APR 2 r i Analyst Remarks: , ❑Unsatisfactory Total Colifonn Present and Ft-Satisfactory f ERS 1N COUIVTY 0 E.coli present 0 E.cah absent _ DEPT.OF CFFERS ITY o Fecal coliform present ❑Fecal coliform absent OEVEIOPM hT Replacement Sample Required: ❑Sample too old(>30 hours) ❑TNTC ❑ ❑Improper Container ❑Turbid culture !m6 E.coli 1100m1. Bacterial Density Results Plate Count______/ml, Total Coliform I100ml. Fecal Coliform /100mI. Date and Time Received'. Method Code: _�.J)LiIt --, 2.DO MICR- 2730 __— -.,--. <, .y.-'6.+_ Dale Reported'W....) -1 ti Date Analyzed. lab Use Only Sample Number(DOH nm�6a plus five Mg ) _ i< -�4'..e.--;( ti {ti 2 —c ( O O v) LJ� % 4 r 1 �-�----� Lab revision ll/14 �, DOH Fam#331.319 Iwise 11n0I ■ TWISS LABORATORIES 26276 Twelve Trees Lane,Suite C Poulsbo,WA 98370 Telephone(360)779-5141 FAX(360)779-5 ISO IOC-SHORT IOC-SHORT by Various EPA Approved Methods Source/Point of Entry-Report of Analysis _ Date Collected: 3/24/2015 Group: Private System ID No: Private System Name: Private Lab-Sample#: 01089302 County: Jefferson Sample Location: 151 Dietz DOH Source No: Sample Purpose: 0 Date Received: 3/24/2015 • Sample Composition: S Date Analyzed: 3/24/2015 • Send Report To: Peggy Klamke Date Reported: 3/26/2015 P.O.Box 2663 Sample Type: Pre-treatment/Raw Poulsbo,WA 98370 Collected By: Peggy Phone Number: 208-553-2241 Bill To: Peggy Klamke P.O.Box 2663 • Poulsbo,WA 98370 DOH# Analyze Results Units SRL 'Trigger- MCL* MCL Method --A� Exceeded (Analyst Init.) • Nitrate-N 0.40 L mg/L , 0.5 5 1_ . 10 EPA 3 0(BK) 20 � 250 EPA 30 0(BK) 21 Chloride 291 mg/1.. i 20 ,_- SRL.: (State Reporting Level),indicates the minimum reporting level required by the Washington Department of Health (DOH). Trigger Level: DOH Drinking Water response level. Systems with compounds detected at concentrations in excess of this level are required to take additional samples.Contact your regional DOH office for further information. MCL: (Maximum Contaminant Level),lithe contaminant amour exceeds the MCL,immediately contact your regional DOH office. NA: (Not Analyzed),in the results column indicates this compound was not included in the current analysis. ND: (Not Detected),in the results column indicates this compound was analyzed and not detected at a level greater than or equal to the SRL <(0.00x): indicates the compound was not detected in the sample at or above the concentration indicated. • The 0.010 mgIL MCL for Arsenic is for Group A NTNC systems. All other systems should check with their county Health District to determine what I vet is applicable Ii-D) eo , „. a i APR - 2 2ov L_�` +)r pr pF CO,di UNITY UNI-1,P ,ENT 147893 • • ��gON ooe". DEPARTMENT OF COMMUNITY DEVELO MENT trz � 621 Sheridan Street,Port Townsend,\V.-\98368 W ; Tel:360.379.4450 I Fax:360.379.4451 Web: ww.co.Jefferson.wa.us/communin•dcvelopment E-mail:dcd@co.iefferson.wa.us ��SkI NCleC PERMIT APPLICATION Steps in the Permit Process: -Review application checklist to ensure all information is completed prior to submitting application. -Make sure septic has been applied for and water availability has been proven. -Make an appointment to meet with the Permit Technician by calling 360-379-4450. -This is not a standalone application;it must be accompanied by a project specific supplemental application. -Fees will be collected at intake. Additional fees may apply after review and payment is required before permit is issued. For Department Use Only Building Permit# Related Application#s: MLA 44 Site Information Assessor Tax Parcel Number: s p (r z f 006" Site Address and/or Directions to Property: i S• ( J t . ,L( QL&t'l ( ' h P LO . Access(name of street(s)) from which access will be gained: tj , Y t a.. 6r f Present use of property: s' ,` G I p -$'0. yin 1 �� r -�� l-�c� c •�' Description of Work(include proposed uses). Wastewater-Sewage Disposal This property is served by Port Townsend of Port Ludlow sewer system? YES _ _ NO — If not served by sewer identified above, identify type of septic system below: teN Type of Sewage System Serving Property: Septic Septic Permit#: ) -e_ p – Od Community Septic Name of System: Case #: Are other residences connected to the septic system? top U '' Additions or repairs to sewage system: Is it a complete or partial system installation: Complete Partial Has a reserve drainfield been designated? Yes _ No _ Date of Last Operations& Maintenance check: Attach last report to application Describe or attach any drainfield easements, covenants or notices on title, which may impact the property: • • (-- S N Co DEPARTMENT OF COMMUNITY DEVELOPMENT G,,,, 621 Sheridan Street,Port Townsend,WA 98368 ■ Tel:360.379.4450 I Fax:360379.4151 Web:www.co.lefferson.wa.usicommunitydevelopment VVE-mail:dcd@co.jefferson.wa.us i N 6fr SUPPLEMENTAL APPLICATION MOBILE OR MANUFACTURED HOME For Department Use Only Receipt#: Date: Related Application#5: Payment it Building Information Property Owner Name: � ql \Cs_� l e Assessor Tax Parcel#: So( ( ( Q Type of Manufactured Home: J l� Check One: New Replacement Moved Demolition Check One: Park On a Lot Temporary Construction Living Quarters Proposed Building/Project: Square Footage: Number of Bedrooms: Type of Heating: Number of Bathrooms: Deck: Sq/Ft: Garage: Sq/Ft: Installer: Address, City,State, Zip: Phone: Installer Email: Contractors License#: Assessor Information Home Data: Make: A4 C.11. I Model: Year: / 7 b Length 5(, Width: 9. c( Serial #: / (usSl ( ‘.;,-r1 ' Your Purchase Price (Don't include sales tax): $ Purchase Date: Previous Owner/Location of Home (if new move to question next question): From whom did you purchase your manufactured home: al OA_ X t ck_ m Address ._ ', y`Vs. "OW\ Was manufactured home assessed in Jefferson County last year: YES NO G) v If yes, Previous address of manufactured home: m 73 If no,what County was M/H assessed in last year: Where is the manufactured home to be located: It Will the home be in a mobile home park? YES NO If located in a mobile home park: Name and address of park: If not located in a mobile home park: Name of land owner: Location address: Assessor tax parcel#: • • 2/24/2015 Shedd Excavating inc. PO Box 179 360-385-0480 Port Hadlock, WA 98339 PROPERTY INFORMATION 1 Location:151 DIETZ DR Tax ID:501031008 Mail To: IRVING&PEGGY KLAMKE 151 DIETZ DR Use: QUILCENE,WA 983769600 Owner:IRVING&PEGGY KLAMKE ON ID: SOM90-00567 rCm r ON-SITE WASTEWATER TREATMENT SYSTEM INSPECTION REPORT Fold • Here Here Inspected:01/07/2015 - Inspection Type:FOLLOW UP - Correction Status:No corrections made • Company. Certification-Level 2 Work Performed By: Submitted 01/082015 y: Shold Excavating Inc. Timothy Johnson Timothy Johnson This report does not assure approvals by Jefferson County Public Health for ANY future building permits or development. COMMENTS&GENERAL INSPECTION NOTES Deficiencies Noted:deficiencies must be corrected to ensure proper longevity of the Onsite Sewage System. • The septic system[sep05-108]is in an incomplete status. • GENERAL SITE&SYSTEM CONDITIONS The General Site and System Conditions were. Partially Inspected All Components accessible for maintenance,secure and in good condition: • Surfacing effluent from any component(including mound seepage): Components appear to be watertight-no visual leaks: Improper encroachment(roads,buildings,etc.)onto component(s): Component settling problems observed: • Abnormal ponding present for one or more of the disposal components: Subsurface components adequately covered Owner compliance issues noted Site maintenance required(e.g.Landscape maintenance)If yes,describe in comments: Occupant compliance problem(occupant not operating the system properly). If YES,describe in notes: If deficiencies were identified on last inspection were they corrected before or during this inspection? (If NO,describe in notes,NA=no deficiencies on last report): OSS Components,structures and appurtenances located per as-built/record drawing(If NO,describe • in notes). If no as-built exists or changes made,state NO and provide record to Health Dept Alterations made to the OSS(valves adjusted,timer settings modified,ports installed,etc.)(If YES, describe in notes): The house/structure was vacant or used infrequently,assessment of the drainfield was not possible. Is the SEP case in a fmaled/completed status?(if NO explain in comments) NO-Deficient ONSITE SEWAGE SYSTEM INSPECTION DETAIL TANK:Septic Tank-2 Compartment This component was: Not Inspected Component appears to be functioning as intended: Effluent level within operational limits(if NO explain in comments): All required baffles in place(N/A=No baffles required): Effluent Filter Cleaned(N/A=Not Present): Compartment 1 Scum accumulation(Inches,if other specify): Effluent filter/screen needed cleaning on arrival Compartment 1 Sludge accumulation(Inches,if other specify): Compartment 2 Scum accumulation(Inches,if other specify): • Compartment 2 Sludge accumulation(Inches,if other specify): • Pumping needed: !Approximate Gallons to be pumped(if needed)by Certified Pumper • • ReportlD:416307 View inspection reports online at www.onlinerme.com Page 1 of 2 • Distribution:D•Box - This component was: Not Inspected D-Box in good condition: D-Box outlets set to allow equal effluent distribution: !i Drairtheld:Gravity !, This component was: Not Inspected Component appears to be functioning as intended: Ponding present?If YES explain in comments: • • This report indicates certain characteristics ofthe onsite sewage system at the time of visa.In no way is this report a guarantee of operation or Mum performance. • • ReportiD:416307 View inspection reports online at www.onlinerrne.com Page 2 of 2 •