HomeMy WebLinkAboutSEP1973-00110903 E. Caroline OLYMPIC" HEALTH DISTRICT Permit Noe-,4�
Port Angeles SEWAGE DISPOSAL PERMIT APPLICATION
Submit in Duplicate Builder
Court House
6I/ie
Port Townsendq. A
PoN_,
DIRECTIONS FOR LOCATING SITE
APPLICATION IS HEREBY MADE TO: INSTALL N34 SYSTEMREPAIR EXISTING SYSTEM _
BASEMENT I . S
.r-
DRAINFIELD LENGTH Q® JIDTH_.2 DEPTH _#LINFSA, SEPTIC TANK SIZE
DRAW A DETAILED PLOT PLAN BELOW. SEE INSTRUCTIONS. SOIL TYPE
IN R qqq
q/`7h
17�r�
,® At
PERMIT UNLESS PRIOR APPROVAL OBTAINED FROM THE HEALTH DEPARTMENT.
DATE OF INSTALLATION SIGNATURE OF APPLICANT,
APPROVED DATE (® INSPECTED BY `' DATE
SANITARIAN'S COMMENTS:
T CERTIFY THAT THIS 1 !0= THE MANNER APPROVED BY THE
HEALTH DEAPR t DATE
'INSTALIERS NAME
v
JEFFERSON COUNTY HEALTH DEPARTMENT Permit #
INDIVIDUAL SEWAGE DISPOSAL INSPECTION FORM Date
APPROVED YES NO ENVIRONMENTALIST
Address Owner
Legal Description
Residence Commercial # of Bedrooms System Installer
System Designer
SEPTIC TANK
Commercial Non commercial Measurements: LW WD
Construction Material Lig. Cap.
DISPOSAL FIELD
Exc. Depth Width Total Length Sq. Ft.
Rock Type Depth Under Over
Engineer Design Yes Type Engineer Approval Letter Yes
Well 50 feet from tank 100 feet from leach field
Well installed at time of septic system inspection Yes No Public Water
Comments: Ito tic rr c ,��n�telas zip .
AS BUILT
DATE
TCA
r'i22 pati
�► _ S Lyle -
ASle -
D/�L`77 Not es s«�
�, > .� �� d
JE��RStN COUNTY HEALTH IMPT. 4W -L- h `+�. a v z Recei t No . f _� ��� `,P
CASTLE HILL CENTER Fee: 615 SHERIDAN g .
PORT TOWNSEND,*A 98368-24392 .2IM
Date:
206-385-9430.
jPF COUNTY
EVALUATION OF 11MIVIDVAL SO&GE DI SYSi' .
..........}..Ai�h_ yr' SUPPLi'
Information, Requested: Indivi&,lual Sewage rispns,_,i �ysta;,
_ Water S.m^ly Public Private
APpl icants Name t-\-,
Address � c ,tY -FT, I .0 s- ,s
Phone: �5 2 ? Z. trLv 0 i2tc�
Previous owner (if faxwn)u1z
Legal Description: Section i< TorAinshi
Street Address /*7,- �j / ��'�, : 4� --\
Nail Completed Reg To:
3r� �-4- JL1 %F p-,-r�
1.6 t4
Number of bedrz.... ooms Z- �.
6r - Year Installed { Q7S" 1 _
p _ /�RarGe ILA/ PARCEL # -Tn-
"1" 'I" Y: I �' -1iM I:A �. ' •' f 1 • • :'i ::A • Y:f f I"
Permitted system V yes no
Installed prior to permit requirement _ v
. es,✓ 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 I_ bedrexam reGidp-nce. This system is not considered
adequate for a � bedroom residene* unles-s it is sized per Current
regulations.
Septic tank should be pumped if not done within past 0 - 5 years.
i.; W;Mz ;� igJ,70V4
Well Casing 12" above ground ves no
Sanitary seal in place yes no
Well 100' from drainfield yes no
Water sample taken yes no
Sample results
5 .
»5/e ' 7:5c- c�-1l�-j -%�J--. 'DiG
lnie}- ci id c�file�- b, ides 147 c�� cvrid:�?�'7 fi-i� `r/� �=��1� �►1i°�7� _
Date 2-Z 73 Time
Environmental Health Specialist
* This report does not constitute a guarantee, either written or implied, that
the stem will continue to function properly. This report constitutes, a
suttm+ary of findings only. 4
EESFOR- .
olo
ZS.c/-.0
TAX
o TOTAL
0608 Recd 4
03-201-3 /IIINTLD IN U.i.A.
NAL7-b Fi.-ttjbE€-
?�
6 190
k
�
"dd9�
Y�
r
olo
ZS.c/-.0
TAX
o TOTAL
0608 Recd 4
03-201-3 /IIINTLD IN U.i.A.
NAL7-b Fi.-ttjbE€-
?�
6 190