HomeMy WebLinkAboutSEP2021-00060 - 01 APPLICATIONJefferson County Environmental Public Health
615 Sheridan St., Porl Townsend WA 98368, (360) 385-9444
SEPTIC SYSTEM PERMIT APPLICATION
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PROPERTYOWNER HANSON
MAILING ADDRESS 7635 MILLS RD MONTEREY CA
PHoNE (30q)
SYSTEM DESIGNER JDG
301-9638 EMATL salmonrun@olvpen.com
Designer Phone #13001551!:9923 EXPIRES 12t27t2022
LEGAL DESCRIPTION: Section 5 Township 30N Range-1W PARCE L# 001 054017
Subdivision Name Division_Block_Lot(s) _
Site address & Directions to site & test pits 2370 HASTINGS AVE W PORT TOWNSEND
park at qate.Perc holes on south east corner and middle of propertv visible from drivewav
Water Source
Private_
Public_/_ Name city of PT
SOURCE OF SEWAGE/USE
Residential r'
Commercial _
Community _
System Type
Conventional r'
Alternative
IVodification Expansion_
Replacement Tank(s)_Drainfield_
Designate Reserve Area_
Redesign_
Tanks only_
Repair_ Tank(s Drainfield_
TYPE OF WORK
New r'
ITE SIZE 5.02 l-lacre
Previous Evaluation No
Yes case
SYSTEM DETAILS
Number of Gallons/day__000__ Soil type____ :[_(attach soil eval.) Application Rate_____0_.6__gal./sq.ft./day
Drainfield Length 350 LF ft. Trench Width 3' ft
ryPE oF SYSTEM qravitv distribution septic svstem (treatment level E)
Chamber size na qal
Trench/Bed Depth 24" in.
Septic Tank size 1500 gal. Pump
By signing the application form, the applicanVowner 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 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 permlt.
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 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 Gounty 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.
CTIARLES HANSON o3t3ot2o21
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