HomeMy WebLinkAboutSEP2019-00049 - 01 APPLICATIONJefferson County Environmental Public Health
615 Sheridan St., PortTownsend WA 98368, (360)385-9444
SEPTIC SYSTEM PERMIT APPLICATION
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PROPERTYOWNER
MAILINGADDRESS
PHONE
SYSTEM DESIGNER
LEGAL DESCRIPTION
(206)271-2435 EMAIL rdfoxOl @msn com & debbie@surbeckortho.com
NATHAN N. CLEAVER Designer Phone # (360) 598-6546
Section 11 Township 28N Range 2W PARCEL# 995400-034. -036. -038 , - o i 1
Subdivision Name SNOW CREEK RANCH Division_Block_Lot(s)qo_
Site address & Directionstosite & test pits 127 CAMP TALBOT ROAD. QUILCENE / So- Hwy 101, L- Snow
Creek Way. L- Skidder Hill Rd. L- Camp Talbot Rd. L onto Property / Soil Logs are in the north eastern corner just
down slooe off of the drivewav.
Water Source
Private_
Public X Name-
PUDSNOWCREEI(
SOURCE OF SEWAGE/USE
Residential X
Commercial
Community
System Type
Conventional XAlternative_
TYPE OF WORKNew_ Tanks only_Modification Expansion_
Repair_ Tank(s)_ Drainfield
Replacement Tank(s)_Drainfield_
Designate Reserve Area-
Redesign X
SITE SIZE tSg'ffsqft .lO
Previous Evaluation
YeS case #-SEPtgJDQlg--
No-
Soiltype z[_(attachsoileval.) Application Rate_0.Q__gal./sq.ft./day
Trench Wdth 3 ft. Trench/Bed Depth 12 in.
PumpChambersize_NA gal.
TYPE OF SYSTEIII SIMPLE GRAVITY SYSTEM
360Numberof
Drainfield Length 200 ft.
Septic Tank size 1.250 gal
By signing the application form, the applicanUowner 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 applicanUowner with respect to this
application packet and void. I further agree to save, indemniff and hold harmless Jefferson
reasonable attomey's fees and expenses which may in any way accrue
in of the granting of this permit.
to County and its employees, representatives or agents for the sole
purpose of application later Staffls access and right of entry will be assumed unless the
applicant informs the Cou tn at the ti of application that he or she requires prior notice. lnspections shall occur
during regular business req notification before entry
Appeal - A person Officer may appeal. Appeals shall be submitted to the Health Division in
writing within fifteen 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 County approvals. For example, it DOES NOT GUARANTEE that you will later
obtain permission to build a permanent residence or other structure on this parcel. Any future application will
be separately judged by the rules and laws in effect at that time.3- ethnl^"$ Oa"o,-t"na l..[ /-l az^- L g
Q Properfy Ou$er Srlnature r
FOR OFFICE USE ONLY *BJfflb,1(r-t4- 14 PARTIAL ASBUILT slail 2?
APPROVED 1-
I NSP/PUMP TEST-!A-Monitoring Agreement
t
ALL HOLD REQ.
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SYSTEM DETAILS
written
Date-Fee-Rec #-check #-case # sEP I4- COOqt