HomeMy WebLinkAboutSEP2012-00020 - 01 APPLICATION Jefferson County Department of Community Development
621 Sheridan St., Port Townsend WA 98368, (360)379-4450
SEPTIC PERMIT APPLICATION
PROPERTY OWNER Eline Dederer TT?"'
MAILING ADDRESS 410 N. ea Dr. '
Port hI B )WA 98365
PHONE (360)437-2468 `
SYSTEM DESIGNER: Michael S. Deenev Designer Phone#: ( 800 ) 395-7296
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LEGAL DESCRIPTION: Section 9 Township 27 Range 1 E PARCEL#934200003 ith
Subdivision Name Bridgehaven L>ud10Lk) Division 2 Block Lot(s) 2&3
Site address/Directions to site 410 N. Beach Dr., Port-He:Reek
SOURCE OF SEWAGE/USE TYPE OF WORK WATER SOURCE
Residential X New Tanks(s)only Private
Residential ADU Modification Public X
Commercial Expansion
Community Upgrade
Repair X SITE SIZE 12,600 s.f.
SYSTEM TYPE Partial Repair-(tank) (drainfield) Previous Evaluation
Conventional Designate Reserve Area Yes#SEP75-00046
Alternative X Redesign No
SYSTEM DETAILS
Number of Gallons/day 240 Soil type 2 (attach soil eval.) Application Rate 1.0 gal./sq.ft./day
Bed Length 24 ft. Bed Width 10 ft. Bed Depth 50 to 55 in.
Septic Tank size 1,000 gal. Pump Chamber size 1,000 gal.
TYPE OF SYSTEM Sand Lined Pressure Distribution Drainfield Bed
By signing the application form, the applicant/owner 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 applicant/owner 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 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.
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Property Owner Si nature Date
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FOR OFFICE USE ONLY /
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PARTIAL ASBUILT 71k l FINAL /4
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INSP/PUMP TEST `1, Vy \1i i� j'1Vr
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C:\Data\W pw\County&State Forms\Jefferson\Septic Permit Forms\Dederer 934200003.wpd