HomeMy WebLinkAboutSEP2005-00253 111
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Jefferson County Department of Community Development 11�a$ y
621 Sheridan St., Port Townsend WA 98368, (360)379-4450 1 4v: •oti
SEPTIC PERMIT APPLICATION 117.4 °; VA\
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PROPERTY OWN Mitch Luckett Al, ' ��
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MAILING ADDRESS 5150 NW Cornell Rd. � ./..,r-`�, ssoons ' ti,
Portland, OR 97210 wit w 1r • •.:...:...... ...-.'..-.... ..:...0
I LICENSED DESIGNER
PHONE Area Code( 503 ) 297-2481
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SYSTEM DESIGNER Paul Gruver dba SoilTech, tele# 360-681-2202
LEGAL DESCRIPTION: Section 17 Township 2 5N Range 2W PARCEL# 50217206\3.A p41 4 lkQOla
Subdivision Name /46,,, NA Division Block Lot(s) -.b
SITE LOCATION - Ove rbrook Ln. , Brinnon, WA Zip Code 98320 `,
SOURCE OF SEWAGE: Residential XX Residential ADU Commercial Community v
TYPE OF WORK: New XX Redesign Upgrade Repair Partial(tank) (drainfield) c„,
Expansion Designate Reserve Area Modification
Conventional XX Alternative Drainfield Length 132 ft. Trench Width 3 ft. l
Number of Gallons/day 240 gpd Trench/Bed Depth 16 in. Number of Lines 4 section A
Site Size 21. 35 acres Septic Tank size 10 0 0 gal. Pump Chamber size NA gal. 3
Water Source: private XX public Soil type GoC-Grover (ATTACH SOIL EVAL.) GLS Sy
Previous eval: ifeVl no # Application Rate 0 . 6 gal./sq.ft./day 5
TYPE OF SYSTEM Conventional Gravity Flow with gravelless chambers Jr")
By signing the application form, the applicant/owner attests that the information provided herein is true and correct to the best of —2_n It
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 p
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 it's employees,representatives or agents for the purpose
of application review and any required later inspections. Access and right of entry to the applicant's property or structure shall be if 0
requested and shall occur during regular business hours.
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. p.,
** See chambers disclaimer on reverse** V
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
futur= application will be separately judged by the rules and laws in effect at that time.
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Septic Permit Application Form_05-10-04_pdf 'Jb
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FOR INFORMATIONAL PURPOSES ONLY-
Jefferson County does not attest to the accuracy of the data contained herein and makes no warranty with respect
to its correctness or validity. Data contained in this map is limited by the method and accuracy of its collection. Fri
Oct 03 14:52:59 2014
http://gisserver/servlet/com.esri.esrimap.Esrimap?ServiceName=... 10/3/2014