HomeMy WebLinkAboutSEP2014-00107 - 01 APPLICATIONJefferson County Department of Community Development
621 Sheridan St., Port Townsend WA 98368, (360) 379 -4450
SEPTIC PERMIT APPLICATIONS ✓e t
PROPERTY OWNER Rick & Christine Esvelt i.( ►��- �ard .4 c—G, r'S-62,1-
MAILING ADDRESS 6450 NE Brigham Road
Bainbrige, WA 98110`
a
PHONE s Me
SYSTEM DESIGNER Suzanne Martin Designer Phone # 554 -0224 "
LEGAL DESCRIPTION: Section 33 Township 3ON Range 1 E PARCEL # 021 33U37 "9
Subdivision Name Betty Hiller SP (enlq by ptn tx 23) 3`` ,
Division Block Lot(s) �
Site address /Directions to site g 3 U f r u;s to{,Q-
,
SOURCE OF SEWAGE /USE
Residential ✓
Residential ADU
Commercial
Community
SYSTEM TYPE
Conventional ✓
Alternative
SYSTEM DETAILS
TYPE OF WORK
New ✓ Tank/s only
Modification_ _
Expansion_
Upgrade, r
Repair
Partial Repair - (tank) (drainfield)
Designate RpGPrve Area
Redesign
WATER SOURCE ,:,
Private
Public—,/
SITE SIZE +/- 84864sf
Previous Evaluation
Yes #
No
Number of Gallons/day-18-0 Soil type 4 (attach soil eval.) Application Rate 0.60
gal.lsq.ft. /day
Drainfield Length 267 ft. Trench Width 3 ft. Trench /Bed Depth 36 in.
Septic Tank size 1000 gal. Pump Chamber size n/a
gal.
TYPE OF conventional trench
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 ;yo laother County approvals. For example, it DOES NOT GUARANTEE that
you will later i ssion to d a permanent residence or other structure on this parcel. Any
future applica weparatt� d by the rules and laws in effect at that time.
Owner Signature
FOR OFF /CE USE ONLY
PARTIAL 'I . S�
APPROVED � AS UILT r' �. � FINAL
3
INSP /PUMP TEST - Pb'D
Date o �' Fee_
c• \n r c �f
forms \Suz \2008 SPA.DOC
ALL HOLD REQ. MET
c'i. 1 60
Rec #
7 ! Check # A) 6
Case # SEP _ I y — ] 6