HomeMy WebLinkAboutSEP2014-00016 - 01 APPLICATIONf h
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House #1
Jefferson County Department of Community Development,.
621 Sheridan St., Port Townsend WA 98368, (360) 379 -4450
SEPTIC PERMIT APPLICATION®
PROPERTY OWNER Michael & Dora Whittaker
MAILING ADDRESS PO Box 220
Quilcene, WA 98376
PHONE ( 360 ) 765 -3157
SYSTEM DESIGNER Suzanne Martin Designer Phone # (360)554 -0224
LEGAL DESCRIPTION: Section 22 Township 27N Range 2W PARCEL # 991 700 001
Subdivision Name River Valley Lonq Plat Division Block Lots) 1 revised
Site address /Directions to site�P'Q Moon Va
SOURCE OF SEWAGE/USE
Residential ✓
Residential ADU
Commercial
Community
SYSTEM TYPE
Conventional ✓
Alternative
SYSTEM DETAILS
WA 98376
TYPE OF WORK
New Tanks only
Modification _
Expansion_ _
Upgrade. r + Ql=
Repair
Partial Repair - (tank) (drainfield)
Desiqnate RPSPrve Area 21111
WATER SOURCE
Private ✓
Public
SITE SIZE +/-23 acre
Previous Evaluation
Yes # S6�° /0 -6 'd
No
Number of Gallons /day 240 Noil type 4 (attach soil eval.) Application Rate 0.60 gal. /sq.ft. /day
Drainfield Length ex=ft' .134rench Width erg ft. j r Trench /Bed Depth Qw-d%'12-inf
Septic Tank size-_e--4329al. Pump Chamber size n/a gal.
TYPE OF #1 (In P1f�..01 -7 6-1 7%1,lno!f4 511 �Ix
By signing the application form, the applicantlowner attests that the information provided herein is true and correct to the best of
their knowledge. Any material falsehood or any omission of a material fact made by the applicantlowner with respect to this
application packet may result in this permit being null and void. I further agree to save, indemnify and hold harmless Jefferson
County against all liabilities, judgments, court costs, reasonable attorney's fees and expenses which may in any way accrue against
Jefferson County as a result of or in consequence of the granting of this permit.
I further 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. Staffs access and right of entry will be assumed unless the
applicant informs the County in writing at the time of the application that he or she requires prior notice. Inspections shall occur
during regular business hours. Initial here if you require notification before entry
Appeal — A person aggrieved of a decision of the Health Officer may appeal. Appeals shall be submitted to the Health Division in
writing within fifteen days after receiving written notice of the decision.
DISCLAIMER -This application is for an on -site sewage system that meets the state and county
standards in effect on the date of application. This application for an onsite sewage system DOES
NOT assure you of any other Coun approvals. For example, it DOES NOT GUARANTEE that
you will later obtain perror ssl to buil= a perry ent residence or other structure on this parcel. Any
future awli�tion wif`be se�ately i.tldaed bhhe rules and laws in effect at that time.
Signature Date
FOR OFFICE USE ONLY /
�� PARTIAL ASBUILT IPW FINAL
INSP /PUMP TEST PUD 7;P
ALL HOLD REQ. MET
G-{ lb ( I q Fee i Zvi tip.., Rec # ' u Check # --7'?— +ri Case # SEP
forms \Suz \2008 SPA.DOC
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