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HomeMy WebLinkAboutSEP1974-00007Jefferson County Department of Community Development Office use 01F ., 621 Sheridan St., Port Townsend WA 98368 (360) 379-4450 Date 7-sy0 1 Evaluation of an Existing Onsite Sewage System Fee 4Y6d -00 Attach plot_IJ19 bovvtng Iodation of: Structures, Drainfield, Septic Tank, Well, etc Repot ALL SPACES MUST BE FILLED IN EXCEPT AS NOTED. Indicate in space if information Check CA6 R is not available (NV) or not applicable (NA). jCase # Type of Evaluation ��\ Reason for Evaluation ❑ Routine O & M Inspection Evaluation of on-site sewage system Ir Real Estate Transaction ❑ Evaluation of Drinking Water KI ❑ Complete a Permit # ❑ Building Permit Review and/or no septic permit on file ❑ Evaluation of on-site sewageDrinking Water 1:1Other I& �l — CDf AA!�z Date of this inspection Inspected by Owner or representative, report to: Name/Address/Phone Current owner &go R G e C. I i a 0 y Site Address 'Al.i R t &Gg PA 1-1 Owner Phone # 4Or�./2riPre ious property owner name (S) if known Parcel # -2m 600 old Subdivision, division, block and lot(s) Qvg&afta 64E r to Permitted System K yes no Permit/case # 7 T Date system instded Age of dwelling # bedrooms House occupied 4 yes no, vacant ow long? Designer Installer L Water supply ` Sample was taken Yes_V--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 fires no, if not, distance Is well more than 50' to tanks and effluent transport line ves no, if not, distance ONSITE SEWAGE SYSTEM #1 - Septic Tank Tank size 1000 gaf.single compartment two compartment material Miser to grade on inlet es�no. Riser to grade on outlet ves no Condition of tank ood needs repair, describe 1st comp. Scum (top layer) 3 in. sludge (bottom layer) < in. 2nd comp. scum in. sludge in. Was ground water observed leaking into tank ? ves, no If yes, where was water observed? Condition of baffles: Inlet 114, 000d needs repair material (PVC,Concrete) Outlet: good needs repair material (PVC,concrete) 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: 0 Onsite Sewage System Inspection Report Page 1 of 3 I. Parcel # S Does system include a pump? "#2 - Puma Chamber Owner Name yes no If yes, complete the next section. 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 ? ves no If yes, where was water observed? 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 #3 — Drainfield j Appropriate Vegetation in area V094es no. Describe vegetation ✓ Indications of surfacing sewage ves , if yes, describe and diagragm on plot plan no overgrown/ not observable Signs of parking/driving in area ves L' no Ground settling or erosion ves no overgrown/not observable Monitoring Port Observations: Residual Head ves, # of inches no Ponding in trench ves, # of inches of ponded effluent no Repair area is adequate _limited none available, describe Complete this section if system is permitted but did not receive an OK to cover or final approval OR there was no septic permit on'file. Describe materials observed in drainfield construction: D -box present yes if yes, material no Drainlines rigid PVC corrugated flex pipe clay the concrete tle seepage pit or cesspool other Drainfield dimensions length width # of drain lines Do observations coincide with permitted system requirements/conditions? _yes no Comments: Onsite Sewage System Inspection Report. Page 2 of 3 Document8 Parcel # Owner Name #4 - Treatment Unit (Sandfilter, Proprietary Device, etc) Appropriate Vegetation in area yes no. Describe vegetation Indications of surfacing sewage ves, if yes, describe and diagram on plot plan no overgrown/not observable Riser to grade? ves no Signs of parking/driving in area ves no Ground settling or erosion ves no overgrown/not observable Monitoring ports in good condition ves no none present/no port found Monitoring Port Observations Residual Head yes, if yes, # of inches no. If no, notify Owner immediately Ponding in trench yes, if yes, # of inches of ponded effluent no Electrical Components Pump operating ves no, if 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 COMMENTS 9VAk a Was a System Problem Identified? Yes if yes, what section #. No I certify that the information provided is based on a review of County records and my direct observations at the time of inspection. Name/Signature Date No guarantee of future performance is implied or granted based on the information contained in this report. This report constitutes a summary of findings only. Onsite Sewage System Inspection Report Page 3 of 3 Document8 • Jefferson County Department of Community Development 621 Sheridan St., Port Townsend WA 98368 (360) 379-4450 MONITORING INSPECTION CERTIFICATION The system serving dJ('- on parcel # , permit #"- was most recently inspected on I by/U�l0� , as specked in Jefferson County Code 8.15.150. The above referenced system is in compliance with the Monitoringlinspection schedule identified in Table 1 of Jefferson Coun;/0 de 8.15. 7 See report completed `� for information on the condition of the onsite sewage system. REQUIRED OR RECOMMENDED REPAIRS/MODIFICATIONS 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 og Table 1 requires that this system receive an inspection: Annually Every 3 years Every 6 years LJ 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. Signature of Jefferson my Employee H:\env_health\linda\GD\FORMS\MONITORING INSPECTION CERTIFICATION.doc C/A I Date r 903 E. Caroline Port Angeles Court House Port ToeTld OkO 'C R R L. r Sep 'ODYMPIC HEALTH DISTRICT Permit No.> SEWAGE`DISPOSAL PERMIT APPLICATION u Subr Duplicate Builder �� 10 a 2. l 'R i cdp b �-', P T, Date C ADDRESS-7'6C PHONE DIRECTIONS FOR LOCATING ,SITE d 1z APPLICATION IS H'MMY MADE TO: INSTALL N34 SYSTEM ✓REPAIR EXISTING SYSTEM YPE OF BUILDING N0. OF BEDROOMS- BASEMENT IT IZ NAME OF S ALLER DRAINFIELD LENGTH qi� l fiDTH DEPTH#LINES SEPT C TANK SIZE ��ye NVO&I 1% rL�,111 uivt,r ,� rxlux APPROVAL OBTAINED FROM THE HEALTH DEPARTMEM DATE OF INSTALLATION SIGNATURE OF APPLICANT APR `�� DATENSPECTED BY SANITARIAN'S COMMENTS: -� ��-�-F` �`^` �. t�k� DAT t ? I CERTIFY THAT THIS HEALTH DEAPRTMENT X arAS INOALLED IX THE MANNER APPROVED BY THE ON-SITE SIEWAGE,�DI.SP&SAL SURVEY OF I. Location, Lot Size Street Or II. System Owner h Address ,-. Telephone Number Permit (?) (Previous Owner) Date Issued III. Installer h _ Average Number of People Served Date Installed '7 Number of Bedrooms Time In -Service (years) Clothes Washer �Q YES NO Septic Tank Pumped YES - NO HO Dishwasher OFTEN # of Months/Years Residence Occupied? Garbage Disposal YES YES NO IV, Type of cover over drainfie.ld. i.e. grass, landscaping, etc.) V. Repairs (when, what, who) Cause of Failure VI. Comments (Over for Sketch) _ VII. Action Taken l _ ,. ,. �� I ' a � � i'�d .,9�p� J� � ~` 1� b'� � ^�_ � I �, ' ` t Y % �� � �. A � � � ,� JU{Li,;,Gf.(,:::R:t, iiLl•L:II:)£ri. CJWTLE HILL CENTER 615 SHERIDAN PORI' TOWNSEND, WA 98388-2438 208.385-9400 Fee: A(,0_+0 b Date: S 9-92 BVArMMO K OF MIIVIDUAAL SHMM DISCAL SYSM AMIOR 16M SM3MY Information Requested: _ Individual Sewage Disposal System _ Water Supply _ Public _ Private Applicants Nww Z) Mail Completed Report To: Owners Name , Address r- ,�, Phone: _� %9 , 1�2 �O Number of bedrooms Previous Owner (if Known)/12,o /Y, Year Installed Legal Description: Section /,�-Tbpmhi _ Z Gu Street Address / ,� " / r, O v Directigns to vroDerty SMM DISCAL Permitted system yes no Installed prior to permit requirement yes �-T0 Sewage noted an grow -4 time of inspection* _ yes no House is unoccupied therefore an evaluation of draiifield performarifae is not possible at this time. A review of our records indicate that this system was designed to service a _�_ bedroom residence. This system is not considered adequate for a bedroan-residence unless it is sized per current regulations. Septic - tarilc shout6\ pxnnp ed if not done within past 3 - 5 years.. ti c; 4.0C,�),pa� --Y"- MMMR \r1\5,,, -,c C,\ Well rasing 12" above ground yes no Sanitary seal in place yes no Well- 100' from drainfield yes _ no Water sample talaen yes no Sample results CCIUMtis: Time Health Specialist * This report does :mot constitute a guarantee, .either written or implied, that the spstem will; VMti:ase to function pr perly. This reroart constitutes a GMMIZY of lSndi>npS only.- HBSI�ORls ocll G12 her b - 5'-q2 ? a.. �ti G®t3OMAN SEPTIC DISPOSAL P.O. eox 233 PORT TOWNSEND, WA 98368 (206) 385.2-qx7 1 0. 1 GOODMAN SEPTIC DISPOSAL P.O. BOX 233 FORT TOWNSEND, WA. 9836G' 385-2557 l'llf. 1 1' Kh . LA^`ftt L htI ll`ll: R R 'C JE . r71 fc ' L c,'E. DR. �. FOR l ) t -WVSE1VD. i-VP. 563&6 JUAN 0 5 1992 ` HE., Cl4g-F_ 6ECrFcCYE" t`I`L 1,t9,,. = PROPERTY 4 c'1 RT t ,E DR. f F'L7)Y T TOUNSEND. Dear`' CARL, the Sep-tic _y,�:jjj �- ;� atacItfe add. has been Gleaned and [-'Iump _yd ctn 5/ ib =,J . �7 � 1 �, i Y :?«�C Working Conditi:_in, ali Ba.*Ff J e are in F'iac ,. and the Drain Field Appear's to be drairei-rig properly. Thank' you for, your Business, and if we can be of any ,ether Service to yon,, car, yoj_t -, + r�rn, please notify we at the above acid. or phone.' Bobbi A. Jevnel owner t ; v I ,•sNx,K:w r..w't�n+6lmeWFKroC:Y:" J+ry • raR!bx6M8iP.Rs":.-aanm•;••••••��•.� W,q �'�+. A E E-1 , MAY 2 Jefferson Counter Planning And Buil'd''ing De04Wt rit Courthouse , 3rd .Floor PO Box :12201. pont Townsend, WA "98368 22038�-914: DATE, RECEIVED .:W19/92. PERMIT.#..:.._BLD92�-p349 SITE ADDRES$:221 RIDGE ;DR PORT T©WNEKD; 'W'A 983,68 PHONE: 3 CARL' DRQW , . MAILING ADDR:221 RIDGE 'DR :PORT TOWNSEND WA 98$6$. SS # .~ -741* CQNTRACTOR..:Na CONTRACTOR PH01_..� " MAKING ,ADDRI. R s, COITR. LIC # : E:�PTRATIC1Ai DATE •f`#3 I D ARCIiTTECT J . f . DESIGNER. � m..AILING ADDR. - - PARCEL .NO .9 Q8C10-01a' HEA WWM, 'TAX BY'' i,RGAL; DES C . : STR 33-30- 02 . : #: F LOT 1C _BLOCK ,` CAPE. GEO VIZI, DIV4' DESCRIPTION OFM IMPROVEMENT mobile ho me irnst�_l�ation �5,44 A-tC$���-- _._---w-- B Raa�s BAxRQa s� �-.-. ' ..-- BUILDING TYPE. OTt ADDL`rIL.� O sf.MOB.FLB EXIST.0iMPR�VEMENT:N EXIST..: 0TYPE.mT K . "'.y GARAGE./CARPORT». ..:: PRC7T' 1 PROP ..:' 1 -.' HTE : . 1 UNHT B 0 mt WOODSTgVE ..........,.. UBC OCCUPANCY GROUP -R3 TOTAL.: TOTAL .:; SEWAGE ars?..: SEPT-rq CARPOR'T,. .. © s : E TYPE QF CONST. .....• WATER _SUPPLY.:PQBLIC C#RAQ9....:`' 0 sf I�S . 0 UNITS.TYPES.DLC :s' STORIES;. O HEAT °: .: , —_--_laHOME Cts P�CIAL R�. " 0 of. �i DT 'lENS'IONS ; ' MAkE:MARLETTE _YR: 92,:, INDtJSTRiAL b .lsf FRAME, TYPEii;, EST CAST.$: 48500 ft SIZE:56 X 28 C ft: Sit SET, PRQ GRP, 2957.. {^yy pyo /: --- .•L_ ff ilk .M .+pR YNs�rr TLw.�. Iw+4: .. a1'Yble, /; •geht 3 ,.., . type araunt .:, by , dale rcpt . PFtMT--S 75.00 AK Q/19IlS 6661 BC,. $.' 4,60 AK t}bj9 6#661 Tiat.e.. Issued By.: r Date _ _ .. _.. n $' 19'. D. TOTAL y • • I VICINITY MAP (directions to your property) CgQ�aLo SAMPLE PLOT PLAN N ,apy PROPERTY BOUNDARIES �tP p0 .t DRIVEWAY 4OJ aATFA Cf y� f SETBACKS IN FST PROPOSED BUILDING �} LOCATION O OF SEPttC MID DRAINFI LOrATION OF WELL TOP OF BANK fIF APPLICABLE) ✓C/CT JEFFERSON COUNTY i UNIVERSAL PLOT PLAN I (This is not a permit) Fill in the following information as completely as possible - Use N/A where the question is not applicable. Property owner name: �qri ,a 0"M i c%g r-6CAV - Mailing.Address: i2 I dy e. r . C \ B WY�,Se -A - zip codeB(o V Site Address/911#: x;\ . L) �=y, s e4^J zip codA Mile Post # Phone# work: i home: C1 14_ LEGAL DESCRIPTION: 9 Digit Parcel # q'4 0 - V00 — 01 0 Section L3—Township j O Range Z Govt. Lot # Tax # j� I Plat/Tract/Addition A 9.-C— GL-o % 1' area/Division Block # Lot i Parcel Area/Size (- 0 X( 3 0 { Proposed Subdivision Name Shoreline Setback 44 4 i — Bank Height Authorized Rep/Contractor/Developer: Contact Phone: Address: POTABLE WATER SOURCE: check one Public Supply °O Port Townsend O PUD O Other Name: QOL04L �cb Cl�,� � State 1. D: Private Supply Z Drilled Well p Other OFFICE USE ONLY Planning Area Fire Dist. School Dist. Land Use Designation Shoreline Designation Project Use: Signature I Date j Screen: 01 Parcel # 000940800010 Geo Cd 300213402161 CAPE GEORGE VILLAGE DIV 4 LOT 10 Mode: INQUIRY Auto Roll: OFF Nbad Cd 5525 * Taxpayer Cd LIBB 3000 LIBBY TRUSTEE, GEORGE C TO Chg Dt 5/01/1997 * Title Owner TO Chg Usr JODI Tax* Code 0161 Status Tx TAXABLE Land Use 1101 MH-REALW/LND Affidavit 81845 Vol/Page l C/U Code S/C Cd 1 1 A AI 11% A //1A //A-! 0%0%-10%0% A 1 A A AI. P7 r% TIAF%