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HomeMy WebLinkAboutSEP1971-00107}Last Caroline ;�'.-Angelaes OLYMPIC HEALTH DISTRICT N Court House, Port Townsend, Washington 9836$ / OLYMPIC HEALTH DISTRICT Permit No. X149 Fee Paid # SEWAGE DISPOSAL PERMIT APPLICATION Submit in Du 14 +,a i ADDRESS r,, r_ ATE LEGAL'DESCRIPTION o ��� r, "��-' 'r- PHONE s ice. �Sp r . A,. il�.I��ii�i rYl�■�■ I liii.l�/ilf�ii�l.■ �iir.Y �. ��Iri• .����� DIRECTIONS ' FOR LOCATING SITE �S? t'� �� C APPLICATION IS HEREBY MADE T0: INSTALL NEW SYSTEM REPAIR EXTZT330 SYSTEM . 'R WO of HIIIING H0 4FBEDR00MS 1BASEMENT 6IZE NAME OF INSTALLER DRAW A DETAILED PLOT PLAN G 1.-P'ope-rtY 3-1ue$ 7. Driveways, patios s carport, etc. 2. -Location of -building 8m Streams or bodies of `water nearby 3.. --Location 4. --.-Location of septics tank 9. Location of percolation test holes 1.Slope of drainfield loo Septic tank size_( Sa�'�s of 6, -Water lines land 110 Length of proposed drainfield & well(if applicable) 12o Depth to water if encountered. PERCOLATION TEST RESULTS epth Time required to Percolation rate. Type of soil Pere. No. ], Of hole seep last 6 in. (divide time by 6) - � A fere-. No. 2 ---- Pere, Pere. No. 3. - D- AINFIELD LENGTH 06, 'WIDTH DEPTH } N0. OF LINES IT_ -IS HEREBY AGREED THAT THE PROPOSED INSTALLATION WILL BE MADE IN THE MANNER AS --DESIGNED AND APPROVED ON THIS APPLICATION. i -APPROX... DATE OF INSTALLAT.TON f Signature of Applicant SANITARIANsS COMMENTS: THIS ONSTITIITES A PERMIT WHF N uV.A Toru r%-MVTn-MT1 r c R TnNT A MTrn M A nnV A DC n C APP PnAT PLAN -APPROVED__ \�:�� _ SAPPROVED DATE 7 `7 -„ DATA:- TN PECT!ED ,SANITARIAN REMARKS: I CERTIFY THAT4 AAS STALLED IN THE PROVED BY THE.EEALTH 5��PARTMENT . f I ST LLERiS NAME DATE L/" UV jefferson. County* Health Department 'A02 Sheridan Ave. Port Townsend, WA 98368 206-385-0722 Receipt No. I 417 Fee: Date:-��- EVALUATION OF INDIVIDUAL SEWAGE DISPOSAL SYSTEM AND/OR W TER SUPPLY r Information Regiested : Individual Sewage Disposal System `s Water Supply Public Private �� Applicants Name GSI f{ (Lj C�y� ,�12� Mil Completed Report To Owners Name ��� - ✓� G,g- Address 2Li I k • =4/ Phone: Number of bedrooms Previous . Owner (if Known) u��a 4�,l�� Year Installed Legal Description: Section _3/ Tomi,ship Range �1 Street Address Directions to property t" loi u 4a/1r'5T 10 G �U c� 13 t 2c N r. v0S FOR HF1elL7H DEPAIMMT USE alljY — DO NO2 IUM BELOW MIS LINE a SEWAGE DISPOSAL SYSTEW Permitted system Y yes no Installed prior to permit requirement yes ✓ no Sewage noted on ground at time of inspection* yes no House is unoccupied therefore an evaluation of drainfield performance 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 bedroom residence unless it is sized per current regulations. Septic tank should be pumped if not done within past 3 - 5 years. WATER SUPPLY Well casing 12" above ground yes no .Sanitary seal in place yes no Well 100' from drainfieloi yes no Water sample taken yes no Sample results nents : tQX 11� Ge%�[�"Le9✓?�' -'Yr 1P�" ✓Jr�'�je3►� e�Tily 1/(�. �e. _ .ryr�,wn,,Ly /S �G�Ci �1e�It.'►{i� ,]SI (� �.�i.•I��/2 Ltr%i �1% DIY 2 9 1991 9 Date 4,-4-'i Time 22: Enviromiental Health Specialist * This report does not .onstitute a guairantee, either written or implied, that ki the system will continue to function properly. This report constitutes a summary of findings only. EESFORM 11/88 • • • .TEI�'�'ERSON �OLJN'T'Sc'' SU°� LL7i NG .A.pPLT CP.3..T`2 ON Jefferson County Planning and Building Department,r 1'`: Courthouse, 3rd Floor PO Box 1220 Z66� ��x<� Port Townsend, WA 98368 206-385-9141 PERMIT #....:BLD92-0280 DATE RECEIVED..05/66/92 SIT" ADDRESS:21 BIRCH CT :BRINNON, WA 98365 ---------------------------------------------- OWNER....... JACK CEDAR PHONE: 796-4843 SAILING ADDR:21 BIRCH COURT :PORT LUDLOW WA 98365 SS #: 091-32-1806 CO;UTRACTO::..:NO CONTRACTOR PH0NF MAILING ADR: CONTR. LIC #: EXPIRATION DATE: FED I.D.: ------------------------------------------------------------------------------- ARC_?ITECT/..: PHONE: DESIGNER..... 'NAILING ' ADDR : ------------------------------------------------------------------------------- PARCEL NO.. :971100-329 HEALTP: _ LEGAL DESC..:STR WM, TAX # BY: DATE: �_- LOT 28 , BLOCK 3 MARSHALL SHORELINES: BY: DATE: �r DESCRIPTION OF IMPROVEMENT: ------------------------------------------------------- single family residence WG- S-/)_qz BUILDING TYPE.......:RES BEDROOMS--- BATHROOMS-- MAIN FL...: 720 sf- TYPE OF IMPROVEMENT:NEW EXIST.: 0 EXIST.: 0 ADD'L FL..: 0 sf GARAGE/CARPORT ..... :A PROP..: 1 PROP..: 1 HTED BSMT.: 0 sf WOODSTOVE.......... :Y TOTAL.: 1 TOTAL.: 1 UNFIT BSMT.: 0 sf UBC OCCUPANCY GROUP: SEWAGE DISP..:SEPTIC CARPORT.... O sf TYPE OF CONST......: WATER SUPPLY.:PUD GARAGE....: 540 sf UNITS.: 1 STORIES:1 HEAT TYPES.:EEE/WOD/ DECKS.....: 0 sf DIMENSIONS: -------MOBILE HOME------ COMMERCIAL: 0 sf FRAME TYPE:WOOD MAKE: YR: INDUSTRIAL: 0 sf EST COST.$: 34200 SIZE: BANK HT... :0 ft PROJ GRP..: 2915 SH SETBACK:O ft Owner/agent---------------- FEES ------- Signature: type amount by date Date: Issued By: ?RMT $ 317.00 MM 05/06/92 PLCK $ 47.55 MM 05/06/92 B.C. $ 4.50 MM 05/06/92 recpt 66587 66587 66587 Date: n- - - - - - - - - - - - - -- - - - - -T - - - - - - - - - - - - - -- KID. *�cua./ $ 369.05 TOTAL f a PLOT PLAN. INDICATE the following information. Draw to scale. Use 1 Square to equal no more than 10 feet. ^ B 1. North arrow C3 2. Property boundaries and dimensions O 3. Driveway/s 0 4. Major features .such as (ravines,seasonal creeks, -bodies of water, etc.) 5. Septic tank and drainfield location, existing or proposed, and distance to closest structure 0 6. Sewer lines D 7. Wells and/or water lines ❑ 8. Neighboring wells within 150 feet 0 9. Paved surfaces (patios) ❑ 10. Structures., existing or proposed, together with setbacks {distances to property boundaries). p 11. Easements for access or utilities 12. Arrows showing direction of slope - assume an elevation of 100 feet at One lot corner and indicate the other lot corner elevations in relation to it. For Applications adjoining shorelines, INDICATE: E3 13 ordinary high water mark p 14. - Top of bank, if over 10 feet high p 15. Slope of bank in degrees INDICATE SCALE of plot plan One inch equals (Grid is in 1/4 inch squares) `COMMUNICABLE PUBLIC HEALTH VITAL ENVIRONMENTAL HEALTH . DISEASE CONTROL NURSING STATISTICS HEALTH EDUCATION JACK CE DAR - l21 BIRCH' BRINNON WA JEFFERSON CO UNTY HEALTH DEPARTMENT 98320 802 SHERIDAN PORT TOWNSENW WASH. 98368 (206) 385-0722 May 21, 1991 RE: Building Permit for 21 Birch in Brinnon Dear Mr. Cedar: On May 17, 1991 the Jefferson County Health Department received a building permit for review. In order to complete our review and give approval for the Building Permit our office must complete an evaluation of the existing system to determine the system's adequacy and that it is functioning properly. An application for the evaluation is enclosed and the instructions are on the back. Please return the application and sixty dollar fee with an accurate plot plan. Please contact our office at 385-0722 if you have further questions. Sincerely, Department of Environmental Health Celia Kadushin, R.S. Environmental Health Specialist CK:ra c: Mike Ajax, Jefferson County Building Dept. Enclosure s VII � a a T �T NC:FFFCTTTAP7?T'.T C✓ ATT C7N Jefferson County 'Planning and Building Department Courthouse, 3rd Floor PO Box 1220 Port Townsend, WA ARS68 206-385-9141 PFRMTT #....:RLD91-0300 DATE.. R.F.CFTVF..D..:05/17/91 STTF ADDRF.SS;21 RTRCH :BRTNNON, WA 98320 ------------------------------------------------------------------------------- OWNF,R .......:.TACK CEDAR PHONE! 796-4843 MATLTNG ADDR!21 RTR.CH :RRTNNON WA 98320 ------------------------------------------------------------------------------- CONTRACTOR..:NO CONTRACTOR PHONE: MATLTNr ADDR! CONTR. T.TC #: FXPTRATTON DATE: ------------------------------------------------------------------------------- ARCHTTF.CT/..: PHONE: DESTGNFR....! MATLTNG ADDR: PARCEL NO....:971100329 HEALTH: LEGAL DFSC.. ! STR 31-25-02 WWM, TAX # BY: DATE! LOT 28 , BLOCK , MARSHALL SHORELTNES: BY! DATE: DF.SCRTPTTON OF TMPROVFMENT: mobile installation permit ---------------------------------------- RTITT.DTNG TYPE ...... :MOB BEDROOMS--- BATHROOMS-- MATN FT....: O sf TYPE OF TMPR.OVF.MFNT:NF.W EXTST.: 0 EXTST. ! 0 2ND FT...... 0 sf GARAGE/CARPORT.....: PROP..! 1 PROP..: 1 3RD FL....: 0 sf WOODSTOVF.......... ! TOTAL.: 1 TOTAL.: 1. BASEMENT..: 0 sf TIRO OCCUPANCY GROUP:R3 SEWAGE nTSP..!SEPTTC CARPORT...: 0 sf TYPE OF CONST ...... ! WATER STIPPT.Y ! PTID GARAGE .... ! 0 sf TJNTTS.! 0 STORTFS:O HEAT TVPF..S.:FFF/WOT)/ DECKS.....! 0 sf nTMFNSTONS!-------MORTLF. HOME ------ COMMFRCTAT.: 0 sf FRAME.. TYPE: MAKE!VAN DYKE. VR:67 TNDUSTRTAL: O Rf FST COST.$: 900 ST7.F:10 X 58 RANK HT... !0 ft PROD GRP..! 1493 SH SETRACK:O ft ------------------------------------------------------------------------------- Owner/agent-------------- FEES =------------- Signature type amount by date rmc- t PRMT $ 7.9.00 ►i 17/91 55762 Date! R.C. $ 4.50 AK 5 1� Tsz3ued Ry: IAY' 1 i 7991 �ItFF, nate:ACf $' ®L q r .^� 79.50 TOTAL ��o PT--------- Id be P L/ 2) Ic^el�� y .i ... �• � � ,.,a` � } � �. Sz ��3��Sr�i�i �=y���X. Y '��,,• +�, x�y��y� 1�•. N .SK�"PC� SCALE --10 ' FEET . BETWEEN LINTS Yv..T... �.z. Ici i Ist (090 s -sot ( sle ow) 'ON3SNAWI iVOd W06 NOISMHSVM GWON 3 3 3dVO 96VZ NOILVIIN" WN WW t r Screen: 01 Parcel # 000971100329 Geo Cd 250231311441 MARSHALL ADDITION BLK 3 LOT 28 * Taxpayer Cd CEDA 1000 CEDAR. JACK * Title Owner Tax Code 0441 Status TX TAXABLE Affidavit 59062 Vol/Page / Mode: INQUIRY Auto Roll: OFF Nbad Cd 1295 T/P Chg Dt 6/12/1989 T/P Chg Usr SR Land Use 1101 MH-REALW/LND C/U Code S/C Cd A r ;.`— .v effer•son County Department of Communft- -,Development- 62,1 Development62'1 Sheridan St, Port Townsend WA 98368 (360) 379-4450 Evaluation of an Existing Onsite Sewage System (EES) Drawn on the back of this sheet a c, urgent 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 (NN) or not applicable (NA). Type of Evaluation VEvaluation of on-site Sewage system ❑ Evaluationof drinking water 13 Evaluation of on-site sewage & drinking water 4 �?f fic�;Use •Only Date —221 6 Fee 3 RecptjQgjQZQ check—L!3-1!9 Reason for Evaluation ❑ u .ne Operation and Monitoring inspection Qin Real Estate transaction ❑ Complete a Permit # ❑ Building Permit Review and/or no septic permit on file ❑ Other, explain Date of evaluation 7-7 f�`r�._ Inspected,b J W Tax parcel # 7 3 Permitted System _yes no Permit/case # SE --11- NV ,Subdivision, Division, Block and Lot(s) Lot Size Acres or Dimension CD%.-Jx,,(> Current Owner �a( . / Site Address 2/ A l ��ye % A9L&8&1/'', WV Owner Phone # Previous property owner name(s) - (N/V if not Directions to Date System Installed 19 �/ Age of Dwelling # House Occupied ves no, vacant how long? Who installed system?___44Z_ s� Send completed report to: Owner Name Mailing Address Phone/email/fax Realtor or Other Representative Name Mailing Address JUL 18 2009 Phone/email/tax AfFfRSON County BCD EES Evaluation Form -07-30-04_W page 1 of 5 S.iD&vwayswd MMM qmw o cererwvIm) o ,nor « . �, '� North ' id& , gam, . OW) PLOT PIAN -date prepared L=j!� �S SeeA- l 7711S v �6 n n �nT-r ebwr z I` STOaAl so F4 # orP `�� /8 © r page 2 of 5 • ._ `.�,• :° :,r;'�`� ems' Plato of InsnPrfinn Inspected by. 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 es_,., no, if not, distance ONSITE SEWAGE SYSTEM # Bedrooms/gallons per day indicated in County Health Dept records for this case_ #1 - Septic Tank Tank size gal - single compartment two compartment - yematerial Riser to grade on inlet es� no. Riser to grade on outlet -_ s no Condition of tank ood needs repair, describe 1 st comp. Scum (top layer) _�_in. sludge (bottom layer) in. 2nd comp. scum in. sludge�, in. _ Was ground water observed leaking into tank ? yes no If yes, where was water obs�ryed? Condition of baffles: Inlet: !/ oad needs repair ' material (PVC,Concrete) Outlet_-oodneeds repair material (PVC,concrete) Screened Outlet n� o _yes, condition dean clogged/dirty Septic tank needs to be pumped (per Jefferson County code 8.15.150 (1) (b)) yes i:z�_no Effluent level at outlet (mark level on circle) If effluent is below the outlet, indicate when tank was last pumped: (e9: Does system include a pump? yes If yes, complete the next section no (if no skip to section 3) #2P_ump Chamber Tank size gal. Material. Riser to grade? Yes no Condition of tank goad needs repair, describe Solids in Tank (see 8.15.150) yes no scum in. sludge in. Was Ground water observed leaking into tank ? I ISTyes no If yes, where was water Ob Screen around pump? no Shroud around pump? dean dirty/clogged Electrical Components / Pump operating yes no, descrit�e High water alarm functions yes no, if no, describe Elec. Panel condition god needs repair, describe Pump cycle drawdown inches. Time for pump cycle Timer Settings min/sec on min/hrs off Floats secured: yes________._no Permit # or Pard # [ z/ Evaluation of an Existing Onsite JUL 18 2000 page 3 of 5 JERMUN LI ily BCD #3 — Qrainfield Appropriate Vegetation in area a/ ves no. Describe vegetatison l /� Indications of surfacing sewage (check one) 6yes, if yes, describe and diagram on plot pian no drainfield area is overgrown and not observable Signs of parking/driving in area yes no drainfield area unknown Ground settling or erosion yes overgrown/not observable Monitoring Port Observations (if present): Residual Head eyes, # of Inches no Ponding in trench yes, # of inches of ponded effluent no Repair area is? Available as shown on permit None evaluated or shown on permit Addendum (page 5) Is attached for evaluation of Treatment Unit or detailed evaluation of drainfleld yes no COMMENTS (attach additional sheet if necessary): P by -i 4 o ci r 4 dpiIN� �v` vve,cr Was a System Problem identified? Yes ____, If yes, what section #. __No JUL 18 2000 J iffidk tu4toI A 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 information provided is based on of records and my direct observations at the time of Inspection. V/ae /vis -- arn ignature Date No guarantee of future onsite sewage system perfo Is implied or granted based on the information contained in this report• This report constitutes a summary of findings only. z. V„ Per4nit # or Parcel gvaluation of an page 4 of 5