HomeMy WebLinkAboutSEP2021-00166 - 01 APPLICATIONDocuSign Q,nvelope lD: 55BE6681 -8D54-424A-8BU-20780F67 13E2
' rL Jefferson County Environmental Public Health
615 Sheridan St., Port Townsend WA 98368, (360) 385-9444
SEPTIC SYSTEM PERMIT APPLICATION
pRopERryowNER Jeff John$n & Bari Bookout
MAILING ADDRESS
PHONE (2!6)972-"226 EMArL
Christooher lvlorton Designer Phone# 360-860-2326SYSTEM DESIGNER
LEGAL DEScRIPTIoN: Section-l-Township-l$$ _Range-1-lAf-PARcEL # 99790001 I
Subdivision Name Villas By the Sea Division-Btock-Lot(s) 19
Site address & Dircctionstosite & test pits 38 Edgewater Court, P
SOURCEOF SEWAGE/USE
Residential
Commercial _
Community X
TYPE OF WORK
New X_ Tanks only-f,_Modification Expansion_
Repair_ Tank(s)_ Drainfield_
Replacement Tank(s)_Drainfield_
Designate Reserve Area_
Redesign X
Water Source
Private_
Public-L Name-
.lefferson PtID
srTE srzE
Previous Evaluation
Yes case
Z,gaO ,"r@
No-
System Type
Conventional _
Alternative X
SYSTEM DETAILS
Numberof Gallons/day--!{L Soiltype-N/A fattach soileval.) Rpplication Rate-N/A gal./sq.ft,/day
Drainfield Length N/A ft. Trench Width N/A ft. Trench/Bed Depth N/A in.
SepticTank size 1000 gal. Pump Chambersize gal.
rypE oF svsreu Septic Tank to existing conventional community system (Villas by the Sea)
By signing the application form, the applicanUowner attests that the information provided herein is true and conecl 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 may result in this permit being null and void. I further agree to save, indemnifu and hold harmless Jefferson
County against all liabilities, judgments, court costs, reasonable attomey'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. 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 afier receiving written notice of the decision.
DISCLAIMER-Th|s 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.
Mt;,;*o*
L0/2s/202L LO/2s/2O2L
Date
FOR OFFICE USE ONLY
PARTIAL ASBUILT
I NSP/PU MP TEsT_Monitoring Agreement 2Z
ALL HOLD REQ.
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