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HomeMy WebLinkAboutSEP1972-00067Jefferson 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 IN. If information is not available enter (NV) or not applicable (NA). Type of Evaluation 1$ Evaluation of on -site sewage system t3 ❑ Evaluation of drinking water ❑ ❑ Evaluation of on -site sewage & drinking water ❑ Office Usp Only I Date 1 l� i b6 Fee Na co Re cpt t nini Check- -, "n_% -t- Case# Reason for Evaluation Routine Operation and Monitoring Inspection Real Estate transaction Complete a Permit # Building Permit Review and/or no septic permit on file Other, explain Date of evaluation _ ©Sj o 50(o Inspected by Q& WUfWft (EffftChOds UA Tax Parcel # 10l9\0CYd30( Permitted System dyes no Permit/case # SEP Subdivision, Division, Block and Lot(s) ®LT�Qs�GA,.•Al o VrLn�.3 Lot Size o3�(^ 1�cre or Dimensions X Current Owner �o �,C o,�„�E? C &I Latkhy-s Site rXM Previous property owner name(s) - (NN if not known) 110K Directions to Sitei�. Date System Installed t -7 Age of Dwelling WN A IE 65ue l # Bedrooms House Occupied yes_ no, vacant how long? "%`1'- Who installed system? RLIS RECEIVED Send completed report to: Owner Name�,o�¢i- Mailing Address Realtor or Other Representative Name ce uow&u— %mitc- Is -.. tLS t�-L*S -A a � Mailing Address Q. a�-1 , +Ra` u &10 til!969 EES Evaluation is orn-r_07- 340- 04_pdf JEEDSON QUM M fb v IE -A\ Qo 6k Or,. LL< page 1 of 5 R Include the following items on your plot plan: ❑ Property boundaries ❑ Names of adjacent streets ❑ Driveways and parking spaces ❑ Surface water (ponds,creeks, etc) ❑ Buildings(residence, sheds, garages, etc) PLOT PLAN-date prepared C>6 2SO(o NNA k 7 'AINF� F , I I AREA E REF ELI 7-0 .W U CA# r "L vp# W FE LL 5:4 fro, er NOT TO SCALE t cl: Wells ❑ Septic tank ❑ Drainfield (enter NN if unknown) ❑ North Arrow REcm��/TD JEFFERSON COUNTY OCR ENVIRWCHECK, LLC. 1612 Hastings Ave. W. Port Townsend, WA 96368 al �i)I Permit # or Parcel # Evaluation of an E)dsting Chsite Sewage System _07/30/04_pdf page 2 of 5 Date of Inspection c7S OLSO(o Inspected by (EtF hides (, U.Q 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 # Bedroomstgallons per day indicated in County Health Dept records for this case nAo,t�ro #1 - Septic Tank Tank size X coo gal. X single compartment two compartment '[ ot.jgA401 material Riser to grade on inlet ves k no. Riser to grade on outlet yes k no Condition of tank X stood needs repair, describe 1st comp. Scum (top layer) 0 in. sludge (bottom layer) in. 2nd comp. scum in. sludge in. Was ground water observed leaking into tank ? _____yes �K_ no If yes, where was water observed? Condition of baffles: Inlet: oo needs repair material (PVC oncret Outlet: oo needs repair material (PV 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 k no Effluent level at outlet (mark level on circle) If effluent is below the outlet, indicate when tank was last pumped: ( eg: 9 ) (3 Does system include a pump? yes If yes, complete the next section _X no (if no skip to section 3) #2 - Pump 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 Tr-,q Screen around pump? no _yes, condition clean d' cl , Uj F) Shroud around'pump? no yes Electrical Components 4,7 Pump operating ves I no, describe High water alarm functions ves no, if no, describe n Elec. Panel condition good needs repair, describe i o 9 D Cll 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 # S F: Evaluation of an Existing Onsite Sewage System _07i30/04 pdf Page 3 of 5 #3 — Drainfield Appropriate Vegetation in area ___)&__yes no. Describe vegetation_ G P ASS Indications of surfacing sewage (check one) -__yes , if yes, describe and diagram on plot plan X no drainfield area is overgrown and not observable Signs of parking/driving in area __yes k no drainfield area unknown Ground settling or erosion __yes K no overgrown/not observable Monitoring Port Observations (if present): Residual Head _yes, # of inches no Ponding in trench _ --___yes, # of inches of ponded effluent no Repair area is? Available as shown on permit X None evaluated or shown on permit Addendum (page 5) is attached for evaluation of Treatment Unit or detailed evaluation of drainfield _yes X no COMMENTS (attach additional sheet if necessary): #1-A. Risen are mandatory on next inspection. other"' The house/ dwelling was unoccupied so no assessment of drainfield could be made. SEE ATTACHED ADDENDUM r4 lu JEFFEDSDN ON BCD Was a System Problem Identified? Yes if yes, what section #. No K 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 formation provided is based on a review of County records and my direct observations at the time of inspection. Name ignature 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 Evaluation of an System _07130/04 _pdf page 4 of 5 ADDENDUM Enviro Check, L.L.C. Company Disclaimer i.: A OWNER ADDRESS LL Ra ?izJ0--%P 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 fines/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 reports, including E.E.S. inspection reports are subject to any change by Jefferson County Environmental Health Department Enviro Check, LLC is not liable for any such changes. 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 cue -v►ti efferson County Ordinances, and to the best of my ability, correct Dale R. WurtsmM Co-Manager SAMPLING {Septic tank) Date- PH Result- DO Result - Temp. Result- MEASUREMENTS Counter Settin "� �K f�- ) Hour Meter- 11FIRSUN COUNR DCD - 943.stat Caroline 47a-oo67 W - HULTH DUTRICT PeTsit- NQ, -4r A& & a Fee Pair. -$ 116 UVAGE DISPOSAL PERMIT APPI►TCAT-IDId i� -or3a SuW#% in Duplicate ?� A MALL DESCRIPTION k o 7-: 4 1w / DIRECTIONS `FOR LOCATING SITE .0t( APPLICATION IS HEREBY MADE TO: INSTALL NEW SYSTEM REPA-IR EXLTZZG SYSTEM s?L-� � LA E `OF ' BASEMENT SITE ' SIZE WAME OF INSTALLER S �UILDIBIC� $i0. OF BEDROOMS N REiTSERS S D , DRAW A DETAILED PLOT PLAN GIVING THE FOLLOWING INFORNLATIG 7 Driveways, patiost carports etc. 2. Location of, building 8. Streams or bodies of water nearby 1 _. atlon. of Septic tank 9. Location of percolat f test hobs 4.- Location of drainfield 10. Septic tank size: I *JJ * -,= S %-Slope of lanil.. 11. Length of proposed drainfield 6"ater lines & saal].(if applicable) 12. Depth to water if encountered. PERCOLATION TEST RESULTS Depth Time required to Percolation rate Type of soi of hole Pere, now I seep last 6 in. (divide time by .Pere.. No. 2 .,:)ere.I�o. DRAINFIELI3 LENGTH ACV. WIDTH `I ` DEPTH 24 "- 3," NO. OF LINES.—L, XT-13 REREBY,AGREED TINT THE PROPOSED INSTALLATION WILL BE MADE IN THE NtCNNER AS- ,DESIGNED AND APPROVED ON THIS APPLICATION. Signature of ApplIcant APPROX. DATI+ OF INSTAIJ AMN NITARIAN tS COMMMS: PLAN - APPROVED DISAPPROVED DATE REMARKS: I CERTIFY THk.T T- SYST.r - INST LED IN THE MANNER APPROVED BY Tp. Hr,4LTE DEPARTMENT. INE&MLR S NAM D.&TE CR 4 r, OQ Q O 9� liJ ��t% . ��; � v M I ko BUILDING PERMIT APPLICATION ' Jefferson County Building Department • County Courthouse • Port Townsend, Wash. 98368 385- 9141 NE I. LOCATION: geographicname S W SIDE OF RO D NE S W FROM INTERSECTION OF ROAD AND other specific location or landmark: LEGAL ES RI ION: C� R_ / Sub sion Pt _ , ✓ .� _ Block 1 .�'� A 11. TYPE AND COST OF BUILDING - TYPE PfIMPROVEMENT w building ❑ Addition ❑ Alteration ❑ Repair, replacement ❑ Wrecking ❑ Moving (relocation) ❑ Foundation only BUILDING TYPE ❑ Single Family ❑ Multi - Family number of units ❑ Hotel, Motel, Dormitory — //''number of units [bile Home her — Specify OWNERSHIP' _ ❑ Private (individual, corporation, nonprofit institution, etc.) r_1 Public (Federal, State or local gov't.) COST 0 Cost of improvement........... $ To be installed but not included In the above cost a. Electrical ................. b. Plumbing .................. c. Heating, air conditioning , , • • • • d. Other (elevator, etc.)........ . • TOTAL COST OF IMPROVEMENT $ .FEET ROAD MOBILITY ❑ New County Resident Is this structure to serve the residential or commercial needs of those employed at either the U.S. Navy's Trident or Indian Island Facilities? ❑ YES ❑ NO USE ❑ Full -time Residence ❑ Second Home: Recreation Cabin, etc. UBC OCCUPANCY GROUP: 0 Second Home: Future conversion to permanent residence (Omit cents) 111. SELECTED CHARACTERISTICS OF BUILDING - PRINCIPAL TYPE OF FRAME Masonry (wall bearing) M Wood Frame 0 Structural steel ❑ Reinforced concrete , t`her — Speci cR r.— __j PRINCIPAL TYPE OF HEATING FUEL ❑ Gas ❑ Oii Electricity ❑ Coal ❑ Other — Specify Nonresidential — Describe in detail proposed use of buildings, e.g., food processing plant, machine shop, laundry building at hospital, elementary school, secondary school, college, parochial school, parking garage for department store, rental office building, office building at industrial plant. If use of existing building is being changed, enter proposed use. SJ A NTY TYPE OF SEWAGE 1 SAL ❑Public or Private. Pndividua septic tan <, et ) DIMENSIONS • Number of Stories ............. *Total square feet of floor area, all floors, based on exterior dimensions ................... •Total land area, sq. ft...... . APPFMf TYPE OF WATER SUPPLY Publlc or private company ❑ Individual (well, cistern) JEFFERSON COUNTY HEALTH DEPARTABENT NUMBER OF OFF - STREET PARKING SPACES Enclosed ..................... Outdoors .................... APPROVED BY: TYPE OF FIREPLACE ISSUE DATE RESIDENTIAL BUILDINGS ONLY Number of bedrooms ............ Number of Full...... . bathrooms Partial.... . ..f TYPE OF MECHANICAL a D9 IV. IDENTIFICATION - Name Mailing Address — Number, street, city and State ZIP code Tel. No. 1. 3D), Owner e an 2. 3. Architect The owner of this building and the undersigned agree to conform to all applicable laws. Signature of applicant A dress Application date PLANNING AREA FIRE DISTRICT SCHOOL DISTRICT WATER DISTRICT APPFMf JEFFERSON COUNTY HEALTH DEPARTABENT APPROVED BY: PERMIT FEE 7S� � ISSUE DATE RECEIPT NUMBER �;- a D9 BUILDING OFFICIAL The Printery — Port Townsend