HomeMy WebLinkAboutSEP2018-00137 - 01 APPLICATIONJefferson County Public Health
615 Sheridan St., Port Townsend WA 98368, (360) 385-9444
SEPTIC PERMIT
pROpERTy OVVNER Samuel Bain
MA1L1NG ADDRESS 60 West Swaney
Port Had wA 98339
PHONE Lglq
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599-1402/email
SYSTEM DESIGNER Suzanne Martin Designer Phone
LEGAL DESCRIPTION: Section 34 Township 30N Range 1W PARCEL#961 804901 3/904/918
Subdivision Name lrondale #2 Division Btock 49 Lot(s) 1-G & 44
Site address/Dircc,tions to sib 40 West Swaney
WATERSOURCE
Privateeuutic-17--
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 applicanVowner 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. Staffls 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. lnspections shall occur
during regular business hours. lnitial 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 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 judged by the rules and laws in effect at that time.
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Property Owner
IEHffi
SOURCE OF SEWAGE/USE
Residential {
Residential ADU _
Commercial
Community _
SYSTEM TYPE
Conventionat {
Alternative_
TYPE OF WORKNew__J_ TanUs only_Modification_Expansion_Repair_
Partial Repair - (tank) _ (drainfield)_
Designate Reserve Area_
Redesign_
SITE SIZE +/-0.39ac
Previous Evaluation
Yes #
No/
SYSTEM DETAILS
Number of Gallons/day 480 Soil type_l_ (attach soit evat.) Application Rate_9.Q9_gal./sq.ft./day
Drainfield Length 267 t. Trench Widft 3 ft. Trench/Bed Depm 12-30 in.
Septic Tank r;r" 1000 x 2 gal. Pump Chamber size n/a gal.
TYPE OF conventional trench
FOR OFFICE USE ONLY
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INSP/PUMP TEST
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APPROVED
l\/l onitoring Agree ment 3- ll-a"tq FIP
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G:\B-ONSITE\Forms\Application Eorm & Info\2015 Septic Permit Application.doc
Date
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