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HomeMy WebLinkAboutSEP1974-00018IT ! j ke,-e-A G. 3 �E. 'Caroline Part Angeles Court House Port'Townsend DIRECTIONS FOR LOCATING S OLYMPIC HEALTH DISTRICT SLVAGE DISPOSAL PERMIT APPLICATION Submit in Duplicate ADDRESS fftfW W Permit No, a,% 3 Builder 1 Date 11 f" ��rr.� j PHONE - APPLICATION IS S( MADE TO: INSTALL NLV SYSTEM REPAIR EXISTING SYSe ` Ft DING Nb. F BEDROOMS BASEMENT T'ITESTL NAME F INSTALhR I J `kp DRAINFI= LENGTH 156 WIDTH I � D #i iN� � SEPTIC TANK SI"LE���, DRAW A DETAILED PLOT PTIAN RFTrna_ AFF TTQAm1?TTrmTnW.Q cnTT. mvDr. 'l ?0, CHANGE INBUILD G OR STAOT DISPOSAL PLANS, LOCATION OR SITE, INVALIDATES THIS R,, PERMIT UNLESS PRIOR APPROVAL OBTAINED FROM THE HEALTH DEPARTMENTS 4- DATEOF INSTALLATION SIGNATURE OF APPLICANT Nk APPRO M DATE S� SPECTER BY 's� $� v DATE 1. /; SANITARIAN'S COMMENTS : I CERTIFY THAT THIS S TEM .,'AS INSTAL I THE MANNER APPROVED BY THE HEALTH D -� ATE INSTALLERS NAME ON-SITE SEWAGE DISPOSAL SURVEY OF Street Or n,v�cinin R1nrle I nt I andmark I. Location, Lot Size II. System Owner Address Telephone Number Permit M (Previous Owner) Date Issued x Lnt' Size -7s X05 � 1 III. Installer Average Number of People Served o� Date Installed ( Q Number of Bedrooms_ Time In -Service (years) Clothes Washer - _ YE S N0 Septic Tank Pumped YES NO HOW Dishwasher .OFTEN YES NO # of Months/Years Residence Occupied? Garbage Disposal A. I YES NO IV, Type of co er over drainfieId. (i.e. grass, landscaping, etc.) VIII. Action Taken L_ 14.efferson County Department of Community Development 44 . 621 Sheridan St., Port Townsend WA 98368 (360) 3794450 Evaluation of an Existing Onsite Sewage System (EES) Draw on the back of this sheet a current plot plan sh4Wl#§ Logia ±pnr+of;; +' Buildings, Drainfields, Septic Tanks, Wells, etc OR, attach _a cuent4) jilt Identifying these items. ALL SPACES MUST BE FILLED IN. If information is not available enter (NV) or not applicable (NA). Office Use Only Date Fee •�� Recpt Check Case # O Type of Evaluation for Etiraluation ❑ Routine operation and Monitoring Inspection Or' Evaluation of on-site sewage system Q Real Estate transaction ❑ Evaluation of drinking water 13 Complete.a Permit # 93"' Building Permit Review and/or no septic permit on file ❑ Evaluation of on-site sewage & drinking water ❑ other, explain Tax Parcel # VDOSZ I Permitted System yes no Permit/case # SEPZ - C 0/Y Subdivision, Division, Block and Lot(s) Lot Size Acres or Dimensions 7 0XA 7S X /S X 176 Current Owner a.,1 4-&s'm A Site Address j 31dma D= Owner Phone # 97f - YTY9 Previous property owner name(s) - (NN if not known) A1�� Directions to ,r Cow A- Date System nm Age of Dwelling 3®4- # Bedrooms House Occupied X yes no, vacant how long? Who installed system? W5= j No+a' Send completed report -to: Owner Name -. Or & Ul Mailing Address /?/ c 444,0� Or { Phone/emaiUfax-?2R .y ? y 9 Realtor or Other Representative Name Mailing Address Phone/emailtfax Include the following items on your plot plan: o Property boundaries ❑ Wells . ❑ Names of adjacent streets ❑ Septic tank ❑ Driveways and parking spaces ❑ Drainfield (enter NN if unknown) ❑ Surface water (ponds,creeks, etc) ❑ North Arrow ❑ Buildings(residence, sheds, garages, etc) 401 PLOT PLAN � �na3PFi V'l 7 �A�� i0 I� permit # or Parcel # Evaluation of an Existing Onsite Sewage S ystern Date of Inspection %® -oS Inspected by -77m Acmg,.,s Water Supplv (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 _yes 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 i®o V gal. j< single compartment two compartment em c fA material Riser to grade on inlet es—_K no. Riser to grade on outlet yes ono Condition of tank it good needs repair, describe 1st comp. Scum (top layer) _5 in. sludge (bottom layer) 3 in. 2nd comp. scum in. sludge in. Was ground water observed leaking into tank ? as K_ no If yes, where was water observed? Condition of baffles: Inlet: A _good needs repair Ca4ce& material (PVC,Concrete) Outlet Rood needs repair CoticZe - -material (PVC,concrete) Screened Outlet _X,no _yes, condition clean clogged/dirly Septic tank needs to be pumped (per Jefferson County code 8.15.150 (1) (b))_ yes _ CLno Effluent level at outlet (mark level on circle) If effluent is below the outlet, indicate when tank was last pumped: eg: 0. 1 Does system include a pump? yes If yes, complete the next section_ no (if no skip to section 3) #2 - Pump Chamber Tank size gal.__z Material. Riser to grade? Yes no Condition of tank good needs repair, describe Solids in Tank (see 8.15.150) yes... no scum in. sludge in. Was Ground water observed leaking into tank ? yes no If yes, where was water observed? Screen around pump?_ yes no Shroud around pump?, yes, no Electrical Components Pump operating ves. no, describe High water alarm functions vas no, if no, describe Elec. Panel condition good needs repair, describe Pump cycle drawdown inches.:Time for pump cycle nin/sec. Timer Settings min/sec on min/hrs. off. Floats secured: yes- ----------no Permit # or Parol #-.3 FZ14D 5 2 Z Docwmentl 3 of 4 T. !Evaluation of an Existing Onsite Sewage System 4 Y L #3 — Drainfieid Appropriate Vegetation in area x yes no... Describe vegetationf� Indications of surfacing sewage (check one) as, if yes, describe and-diagram.on plot plan Xno r•o - -\ drainfield area is overgrown -and not observable Signs of parking/driving in area yes_ no _ drainfield area unknown Ground settling or erosion --Yes _no pvergrown/not observable Monitoring Port Observations (if present): Residual Head yes, # of inches~ no Ponding in trench ves, # of inches ofponded effluent- no Repair area is? Available as shown on permit None evaluated or shown on.permit Addendum is attached for evaluation of Treatment Unit or detailed evaluation of drainfield es_4-no COMMENTS (attach additional sheet if necessary): 4,o rtye-fs71 ®" rasps Was a System Problem Identified? Yes if yes, what section -t. ,No 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 tIM8. 1 certify that the information provided is ba n a review of County records, and my direct observations at the time of inspection. Name/Signature Date No guarantee of future onsite sewage system performance is implied, or granted based on the information contained in this report, This report constitutes a summary -of findings -only: Permit # or Parcel # 93I' Y0OS-2-1- Eh=ffantl 4 of 4 evaluation of Existing Onsite Sewage System - Addendum Date of Inspection Inspected by #4 - Treatment Unit (Sandfilter, Proprietary Device etc) Appropriate Vegetation in area ves no. Indications of surfacing sewage as , if yes, no Riser to grade? ves no Signs of parking/driving in area yes G dttl' and diagram on plot plan irown/not observable roup se inu or erosion s no overgrown/not observable Monitoring ports in good condition as no none present/no port found Monitoring Port Observations Residual Head ves, if yes, # of inches no. If no, notify Owner immediately Ponding in trench v if yes, # of inches of ponded effluent no Electrical Components P>water g es no, if no, describe Hfunctions ves no, if no, describe FJndition goodneeds repair, describe Pawdown inches. Time for pump cycle min/sec. T min/sec on mWhirs off Floats secured ves no Section below line to be completed only by Licensed Designer, Professional Engineer or Health Department staff #5 - Detailed Drainfield Evaluation Complete this section if system is permitted but did not receive an OK to er or final approval OR there was no septic permit on file. Describe materials observed in drainfield construe ' D -box present yes if yes, material no Drainlines rigid PVC corrugated flex pipe clay file concrete tile seepage pit or cesspool other Drainfield dimensions length width # of drain lines Do observations coinc' with permitted system requirements/conditions? _yes no Soils in area of dr ' field evaluated? ves no If yes, descri soil profile below and identify location on plot plan. What is vertical separation from the bottom of the drainfield trench to a restrictive horizon? Inchestfeet Comments ach additional sheet if necessary): Permit # or Parcel # \\Healthserver\homelenv health\linda\GD F0RMS\20000ns(te Inspection Form Adden1-1-1 7­01.doc 7y- 00/ DATE ADDRESS !�/ ��oc-•��v^' ADDENDUM OWNERS A*A-f S m BERNT ERICSEN EXCAVATINQ INC. Company Disclaimer Based on what we were able to observe and out experience with on-site wastewater technology, we submit this Evaluation of Existing Onsite Sewage System (EES) report based on the present condition of the on-site sewage treatment system. Beret Ericsen Excavating, Inc. has not been retained to warrant, guarantee, or certify the proper functioning of the system for any period of time in the present or future. Because of the numerous factors which may affect the proper operation of a septic system, this report shall not be construed as a warranty by our company that the system will function properly for any particular buyer or owner. Bernt Ericsen Excavating, Inc. disclaims any warranty, either expressed or implied, arising from this inspection/evaluation of the septic system or this report /evaluation. We are also not ascertaining the impact the system is having on the ground water or environment. Bernt Ericsen Excavating, Inc. does not make any claim, warranty, or guarantee as to where property lines/boundaries of properties are located. And does not warrant or guarantee any encroachments from on site sewage systems on to adjacent properties. Any indications of possible property lines/boundaries are approximations and do not indicate legal property lines or boundaries. Beret Ericsen Excavating, Inc. will not be held responsible in any way for information being undisclosed (intentionally or unintentionally) by property owner, representative or other parties of interest. All parties are encouraged to check county records for any information regarding properties. Bernt Ericsen Excavating, Inc. 2323 Hastings Ave. West Port Townsend, WA 98368 360-385-3602 I acknowledge th all information is done to the best of my ability, correct. Tim Thomas, Licensed 0 & M Specialist BUILDING PERMIT APPLICATION MR Review 7 Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD06-00597 Received Date: 10/17/2006 SITE ADDRESS: 131 E RHODODENDRON DR PORT TOWNSEND, 98368 OWNER: SANDRA B SMITH PHONE: 608-592-4611 MICHAEL W SMITH 225 PALMER PKWY LODI WI 535551124 CAPE GEORGE COLONY DIV 3 SUBDIVISION: Block: 5 Lot: 23 PARCEL NUMBER: 938400522 Section: 12 Township: 30 N Range: 02 W CONTRACTOR: REPRESENTATIVE: OWNER/BUILDER PROJECT DESCRIPTIOP NEW DECK PHONE: PHONE: TYPE OF WORK RES SQUARE FOOTAGE: Exist: TYPE OF IMP DEK Total: Total: VALUATION 7,542.00 MAIN: 10/17/06 10/17/06 CODE EDITION: 2003 ADD'L: HEAT TYPE: OCCUPANCY: HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: # OF STORIES: CONST TYPE: OTHER: SHORELINE: CONST TYPE: GARAGE: SETBACK: DECK: 320 BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: BEDROOMS: BATHROOMS: Exist: Exist: Prop: Prop: Total: Total: Routinj Dat $99.61 $4.50 0 10/17/06 10/17/06 85099 85099 I 10cp Type Amount Paid Bv: Date: Receipt: Approved/Date Permit $153.25 LYK 10/17/06 85099 Plan Check State Building Code $99.61 $4.50 LYK LYK 10/17/06 10/17/06 85099 85099 I 10cp Total: $257.36 t�` it it I A A it L -i J t -4 — 14 I J. ! i•-tR}� i'.s. 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