HomeMy WebLinkAboutSEP1977-00106 903 E. 4 IC" �m .;" .* '.
1 es, SAGE ' • s P "`- ,
45%$583 submit , _ , ._
ckft 802 Sher �_,: Date
: `*aa .3 \c 11 4t a Yw tal ' titW
A :. ' " i
lq
;� �
•, , rib 'Ili` s A 4 �° �� .
#. Y
TYPE OP M II hig14 III' * OF/ CND :*'. q'itii • '''''' -4' ..;..
tT- ems; A? , 4.1 :z,v;- E4ziiii' s ., = **r, , 4 ,,,,,,,,, gt
- \ - 0 ' ' 41)04+104i64%.'''' ''.474*4'
,, - - , ./.\\() , -, , ,
, , , , iii.440' , :1'
1I� ® � � 'tom,, � �
tt Ib '' l', ,,,„
' It .7' 4 C4c-**'611t' ‘ ''. 4.''v.. 1 ? 4.°''
,, C/*
fr o� 9 1 d�. a l,1 ',►.i ' 4�+ cf 11 /N , '1 '/
.: - ';
' ' Of 'N4III.' ' ' '
N T I 'S "t 3TS: ,
' - ' "
@4,. . .� Vas ''`,- Ci
r
N
SEE REVILIISE S , r PM , S 1W
OHD 4.77 #6,4 �: , ',
V
A
Kbf Xr�
'\ '4':',I,ff �' §.tk i 1 !� S rx�
\' 5 . t $ ' ,
1 - `ae "'4'c. F «mx „ µ2 L -..yy.rp.
,.w,kes,a. a'cw+R .:: -....d.-.wtn. K 3.
ng#',aw- _ ,yy
��
„„<. r, � T wYh y rt k /l4raw
///,/
4
'A iAJ� \
.:. .. • �"'r'�,.".14-14'° ''''' ,-.mss.-..� ''b"^'• ,.�...w� ..�. +,+�+
i f , , .;,''-1-a � � V,t A t,„4;„,..„ �
�,:,��}e ' � 1 �>`�Mc�� "¢''J �� °� ¢ + F'��k��a+r,p„ e ti ' Y r'C @
ir
! w
0 JEFFERSON COUNTY PUBLIC HEALTH
-P'vq/tit.',"Ai? 615 Sheridan Street • Port Townsend •Washington •98368
www.jeffersoncountypu blichealth.org
CERTIFICATION OF TANK ABANDONMENT
Parcel number o 1 00
Address 1,C'� 'M,y vc kk) , ►`∎y(
Property Owner Name iAdr C15")0-1. €4.1kA -",--N4- 6-i(t 10
Septic Permit# (if applicable)
Individual/Company Certifying Abandonment
_ 1 lie
Phone Number p(7 -3Le33
I certify that the septic tank and/or pump chamber on the above referenced site
has been abandoned to Washington State and Jefferson County Public Health
Requirements.
Signature : Date �,_ ��
Print Nam—as .
Pump receipt attached
COMMUNITY HEALTH ENVIRONMENTAL HEALTH
PUBLIC HEALTH
DEVELOPMENTAL DISABILITIES WATER QUALITY
ALWAYS DORKING FOR A SABER AND
MAIN: 36(}3$5-9400 MAIN: 360385-9444
FAX 360-385-9401 HEALTHIER COMMUNITY FAX: 360385-9401
•
'
• Arness Septic Pumping
22777 Indianola Rd NE
Poulsbo, WA 98370
Customer's
Order No. . Date 4. -�-
Name '
Address (>2(J �[ (I
12 0 —loS7)
SOLD B CAS C.O.D. CHARGE ON ACCT. MDSE.RETD. PAID OUT
QUAN. DESCRIPTION PRICE AMOUNT
are if rrive
• .rt
A.
Va tiff! '.
All claims and returned goods MUST be accar anfed;,:!is bill TAX
97463 Received by All TOTAL
� '6 r
• BUSINESS FORM 55-58BT MADE IN U .A. ,f�
Al
rIM• • i•%MMI•S MI/NW•••III• • • 1••i•viw•f• M a aYawa,u•■ warns..............
SEPTIC TANK PUINPIN as INSPECTION REPORT FORM
Cite HE Center—615 Sheridan, Port Townsend,WA 98368
Z eh. .,L/_, fl) fliQdOJ}L adeah_o_ .95'374
Nacre of Ownes Conte t Person / Address City .•Zip Code
Date of inspection '''w2/•--/.7/ . Assessors account* q9/o?o/013
• SEPTIC TANK k
Esumsied Tank size1� ❑ METAL . .• .:
jCONCRETE 0 POLYETHYLENE . •D•aort ;:,
El tdence of ground water intrusion? ❑ YES ❑ NO .
:s tank greater than 12"below grade? .❑ YES* ❑ •NO •If"YES",how deep(inches)?
:s a user installed? ❑ YES ❑ NO
Effluent from drainfeld backing into tank? n Yne 0 NO
u NO
�st=.tttwr,of baffles. [� GOOD 0 NONE [] NEED REPAIR ttraer ta.sreasrwc�orwtaersy
fI_en:screen, cleaned? ❑ YES 0 NO 0 NONE ❑ NEED REPAIR to ass e.vectf :s ecu,a:r s.
:Vu the Septic Tank pumped? YES ❑ NO
ere both cats pumped? YES ❑ NO 0 SINGLE COMPARTMENT
PUMP TANK . .. . .
(cheek If applicable) . .
•
Is there 3 pump tank? ❑ YES ❑ NO
•
.s 7 nser installed? ❑ YES 0 NO
IS tank greater than 12"below grade? ❑ YES* ❑ NO elf"YES",how deep(inches
Estimated PumpTank size ,gal, ❑ 'METAL . ❑ CONCRETE ❑ POLYETHYLENE 0 OTHER marred ooawt.n
:4':s the Pump Tank pumped? ❑ YES ❑ NO* •If"NO",
explain in comments.
r_:tp Tank screen cleaned(if present)? 0 YES 0 NO* . *If"NO",explain in comments. : .
IF MEASUREMENTS WERE TA KEN Ow SCUM.AND SL.JD;E LAYS,PLEASE RiCOIeD BELOW:
. 1ST COMPARTMENT 2ND COMPARTMENT '
:):pin of floating mat in 1st compartment inches Depth of floating mat 2nd compartment mows
Depth of sludge in 1st compare nent ______inches Depth of sludge in Ind compartment . - . inches
• Total depth including asst,sludge and clear zone inches Total depth Ind udi mat,sludge and agar-nix- _; _ ietttta
cos►Ib1ENTS, -7-. ,--g ../.0 44,4e/7 eke .
ya0.-
_! . ATURE OF PUMPER / / / . PUMPING COMPANY MOMS.S SS ►Pu �ngi•Vets report indicates the condition•f the • septic tank(s),and/or pump tank(s),at the time of inspection and pumping. In no way does u guirsntce utM
::•they will continue to function sapsfactotily.
'WAC 246-272.15501 The 0SS owner shalt employ an approved pumper to remove the septage from the tank when the solids and the setnri•itd icate
Day t removal is n_eeemtrwt d iggigjgasho rld be i rspeered every three years and p upped only when needed If the combined sludge antsolies creed•1;1
:iie total vellum of the first compartment and/or 1/3 of the total Vitale ofa single compartment tank,p (/the sludge layerfs leis the 12 brrhes front me
:,trout of the outlet tee and the floating sat is lest than 3 inches front.the bottom of the owlet tee or!inch from the top of the outlet tree.then*tank sho:.ia.
oe pumped. (the tank is pumped toe often however,the proper separation and biological treatment occurring in the tank can be inrpairtd leading to possible -
-. ._ ._'./..tow w CIK/Inf Arnarg ONMA Twwt. .Lo .1d A. .....n.d...A.. .,...._..i...»_....r_c../... _---