Loading...
HomeMy WebLinkAboutSEP1975-00066.j Jeferson County Department of ,Community Development 621 Sheridan St., Port Townsend WA 98368 (360) 379-4450 Evaluation of an Existing Onsite Sewage System (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 1N. If information isnot available enter (NV) or'not applicable (NA). Office Use Only Date % j% Fee /,01f (�U/ Recpt (O Sbl0 Check ZU / Case # )5_10(0 iD Type of Evaluation Reason for Evaluation 0 Routine Operation and Monitoring Inspection 19 5valuation of on-site sewage system Real Estate transaction , O Evaluation of drinking water O Complete a Permit # 0 -Building Permit Review and/or no septic permit on file 0 Evaluation of on-site sewage & drinking water ' 0 Other, explain Tax Parcel # �q 12064al Permitted System dyes no Permit/case # SEP'1ff.-(*(&. Subdivision., Division, Block and Lot(s) G vl_aj T Lot Size cre or Dimensions X Current Owner Site Address ko T.swur- & Owner Phone # �y Previous property owner name(s) - (NN if not known) t►ss Directions to Site F.h.- Wil$-' w - ,_ SIS 4lw.. tot, -Q S ReeGE�_ I8 Date System Installed Q—` 15 Age of Dwelling A 40 q # Bedrooms _ House Occupied kyes no, vacant how long? Who installed system? Send completed report to: Owner Name C>Laol ko' . A�w-w6 Mailing Address Q.0.7n.&xyk% Phone/email/fax Realtor or Other Representative Z Address !?.o Rex :1 no,, Q .,% cEivE -Vzs. R83'76 fto ' Include the following items on your plot plan: ' ❑ Property boundaries o Wells ❑ Names of adjacent streets ❑ Septic tank ❑ Driveways and parking spaces _ ❑ Drainfield (enter NN if unknown) ❑ Surface water (ponds,creeks, etc). ❑ North Arrow ❑ Buildings(residehce, sheds, garages, etc) j _ So�fty. sT W pS i140 � ,p q�ysa1� Aid►; 4 O L„�o►4rS� o u►946 1 NOT TO SCALA ENV/RL.L.C. 1612 Hastings Ave. W. Port Townsend, WA 913368 Permit # or Parcel # '��. 5? •'ls ` Dmmentl 2 of 4 ., Evaluation of an Existing Onsite Sewage stem Date of Inspection n --i k4o!j Inspected by Water Su,ipt* (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 ohsite 1s 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_\4D 41 - Seatic Tank Tank size —] 50 gal.single compartment two compartment �e=�— material Riser to grade on inlet ves X no. Riser to grade on outlet ves X no Condition of tank X good needs repair, describe'. lit comp. Scum (top layer) kf ,, in. sludge (bottom layer) kn�. in. 2nd comp. scum in. sludge in. Was ground water observed leaking into tank ? ves - — no , If yes, where was water obs Condition of baffles: Inlet ,k. ' repair material Outlet:oo x needs repair material (PVC ncret ) Screened Outlet.—,_no _yes, condition clean clogged/dirty Septic tank needs to be pumped (per Jefferson County code 8.15.150 (1) (b))�_ yes no Effluent level at outlet (mark level on circle) If effluent is below the outlet, indicate when tank was last pumped: ( eg: ) Does system include a pump? yes If yes, complete the next section _� 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? Screen around pump? ves no 'Shroud around pump? yes no Electrical Components Pump operating ves no, describe High water alarm functions yes 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 # Docurnentl 3 of 4 Evaluation of an Existing Onsite Sewage System , #�3 - Drainfield -Appropriate Vegetation in area dyes no. Describe vegetation �.itwss seE �, Indications of surfacing sewage (check one) ves , if yes, describe and diagram on plot plan X no drainfieid area is overgrpwn and not observable Signs of parking/driving in area_yes _no _ drainfieid area unknown Ground settling or erosion Yes )_no overgrown/not obseNable Monitoring Port Observations (if present): Residual Head ,yes, # 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 is attached for evaluation of Treatment Unit or detailed evaluation of drainfield _yes -.&_no COMMENTS (attach additional sheet if necessary): �,, Q�`�5�.�•4 A Mi1"W01L0t 11.5 "ZP46Q o>v -. J�.+�� ♦/'VT 1S V1►:DEQ ��1 0� ♦� VP�VGWA4 r���v C�4E� a j Ivo ►U>w G 0sa. X", ChKJV t--1 AJr aF 4",3- -s o, r'• <Ww.2A&'6 'S^fMAnH C� AR R.AC.k AOfr ISA ANo Do wsr T�\tQz CI~OA��s ©�'Nif,R.�P.�►�>aF��lfl 1��A• s%v\z .,o a v'C C Ei'R� Wowatsr XNI Fkry-a s QvWlue SEE ATTACHED ADDENDUM Was a System Problem Identified? Yes X if yes, what section #. No _ 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 inspec • . 0-1 `Soy, Name/Signature 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 Parcel Documentl 4 of -4 D' # C -,V DATE n_7 11 oy ADDENDUM ADDRESS Io OWNER k--oL iAz M&)r, Enviro Check, L.L.C. Company Disclaimer 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 impligd, arising from the inspection/evaluation of the septic system or this reportlevaluation. 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. Enviro Check, L.L.C. will not be held responsible in'any, way for information being undisclosed (intentionally or unintentionally) by property owner, representative or other parties of interest. All parties are encourages -to check county records for any information regarding properties. 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 accor �_•*'.�:.Rff County Ordinances, and to the best of my ability, correct. Dae R Wurtsmith Co -Manager or Steve Bell Co -Manager Weather Conditions SAMPLING (Septic tank) MEASUREMENTS Date - PH Result - DO Result- Temp- Result - Counter Setting - Hour Meter - Water Usage (Ave.GPQ Meter - Squirt Height (In feet)- 903 E. Caroline Port Angeles Court House Port To end I DIRECTIONS FOR D SEPI X06( OLYMPIC HEALTH ISTRICT SEWAGE DISPOSAL PERMIT APPLICATION Submit in DUlicate $ui'fider 'ate APPLICATION IS HEREBY MADE TOj INSTALL NEV SYSTIRPAiR EXISTING SYSTEM YPE OF BUILDING NO, EDROOMS BASEMENT.. :SITE S3ZA�ME 0� TA DRAINFIELD LENG 'UDTH_4gLDEP 9 #LINE42' SEPTIC TANK SIZE DRAN A DETAILED PLOT PLAN BELOW. SEE INSTRUCTIONS, SOIL TYPE r NP ANY CHANGE IN BUILDING OR SE'.'AGE DISPOSAL PLANS, LOCATION R SITE, INVALIDATES THIS PERMIT UNLESS PRIOR APPROVAL OBTAINED FROM THE HEALTH DEPARMTT. DATE OV INSTALLATION SIGNATURE OF APPLICANTx, WA DATE ! ? NSPECTDATE SANITARIAN'S COMMENTS: I CERTIFY THAT T T,z IN 19� 9 . HEALTH DEAPRTM�..�1T THE MANNER APPRCA STA. NAME ^1 Parcel Details Page 1 of 2 Parcel Number: 991200401 Owner Mailing Address: CAROL WLAZNAK PO BOX 248 QUILCENE WA983760248 Site Address: 10 FREMONT AVE QUILCENE 98376 Section: 24 Qtr Section: N E 1/4 Township: 27N Range: 2W School Dim: Quilcene (48) Fire Dist: Quilcene (2) Tax Status: Taxable Tax Code: 320 Planning area: Quilcene (10) Printer Friendly Sub Division: QUILCENE Assessor's Land Use Code: 1101 - MOBILE HOMES (owns mobile & land) Property Description: QUILCENE I BLK 4 LOTS 1, 2& 3 l 1 Click on photo for larger image. Permit Data assessor Bldg Data hx, AN, Salesa Parcel �lats & S rye s war i HOME I COUNTY INFO I DEPARTMENTS I SEARCH j Best viewed with Microsoft Internet Explorer 6.0 or later Windows - Mac Map output Page 1 of 1 ArcIMS HTML Viewer Ma LIh9sER CONGER RO 4+332W7e2So 9372M760t ''1 QUILCENE AV U0N1rAV Legend [_!!!A"17Selected Features Towns 9912x00402 X39 012Q 403 "a * Rw;� Cav 98 702"V F- I FWad System Ra"Is- l Boundaries �992t6� '97 7AL-1 991200407D M2W302 Mega tr .tefteracm emNly catret SWWAW W a is rt PURPOSES ONLY - LORFORMATIONAL n County does not attest to the accuracy of the data contained herein and makes no warranty with to its correctness or validity. Data contained in this map is limited by the method and accuracy of its n. Fri Jul 16 07:00:58 2004 SEP I 5 903 E. Caroline OLYMPIC HEALTH DISTRICT Permit No.� Port Angeles SEWAGE DISPOSAL PERMIT APPLICATION Submit in Duklicaie 18UiI 3fi Court House Port Tow- nsend 444, ate .t DIRECTIONS FOR LOCAT NG SITE$ , /IV 144-92 5 a�� :14-610 APPLICATION IS HEREBY MADE T03, INSTALL NM4 SYSM4- )6tPAIR, EX,I.STING SYSTEM YPE OF BUILDING N0 BEDROOMS • BASEMENT.. yye BITE SIZ NAE 0 STA: DRAINFIELD LEND 0�64 ��!IDTH DEP SEPTIC TANK SIZE .. DRAW A DETAILED PLOT PLAN BELOW. SEE INSTRUCTIONS. -SOIL TYPE �- '' ANY CHANGE IN BUILDING QR SW AGE DISPOSAL LOCATION' 3R' SM, I, PERMIT UNLESS PRIOR APPROVAL OBTAINED FROM THE HEALTH DEPARTMLNT, DATE OV INSTALLIA'TION SIGNATURE OF APPLICANTYt �PED DATE!J02-LINS PECTED BY �� DA SANITARIAN'S COMMENTS: I CERTIFY THAT HEALTH DEAPRTM IN THE MANNER APPROVED BY THE DATV .