Specifications Office Use Only:
PERMIT NUMBER: /0 00(08 FEE: $ 746,00
DEPARTMENT OF HEALTH & HUMAN SERVICES
oaFCON Environmental Health Program
Onsite Wastewater Treatment System Construction installation Permit
❑ NEW CONSTRUCTION ❑ REPAIR ALTERATION ❑ RENEWAL ❑ OTHER
❑ Major ."Major
❑ Minor ❑ Minor
PERMIT ISSUED TO: AFIZIL 0 ELK E 25 I W 'MA Soo
2 � ! -
Property Owner's � Name Township Range Section Tax Lot/Acct.#
14 336 .5W 1 5 A\IE1�Joe. 7 ),7
�..te Site Address Nearest City or Community
�-- O
Is• ued by - Signature Cate I f sued Ex ration Date
Type of Facility erved: -: Single Family Res. # Bdrms: 5 ❑ Other — Specify:
Max. Peak Design Flow: 525 Gal/Day
All work must conform with Oregon Administrative Rules, Chapter 340, Divisions 71 & 73. Work must be done by the
permittee or by a licensed sewage disposal service business. No changes In system location or specifications may be
made without written approval from the Washington County Environmental Health Program.
SYSTEM SPECIFICATIONS
Type: Standard ❑ Capping Fill ❑ Seepage Trench ❑ Seepage Bed ❑ Pressurized Distribution
❑ Tile Dewatering ❑ Sand Filter ❑ RGF ❑ ATT:
Manufacturer /System Type /Model #
Treatment Level Reg' ireri: r I I or n 11 ❑ Disinfection I Init:
Manufacturer /System Type /Model #
SEPTIC TANK SPECIFICATIONS NEW ❑ EXISTING
Min. Septic Tank Volume: 1 Gal Min. Dosing Tank Volume: Gal
Special Requirements:
DRAINFIELD SPECIFICATIONS NEW ,❑ EXISTING
Media Type: X r2ock /Pipe ❑ Other (Product /Manufacturer):
Trench Specifications: 438 Linear Ft. S'74, Ft. Undisturbed Soil Between Trenches: 8 feet
Max. Depth: 24 inches Min. Depth: 24 inches Total Rock Depth: )2. inches
Rock Below Pipe: G in. Rock Above Pipe: 2- in. Capping Fills — Min. Depth of Fill Material: in.
Special Drainfield Specifications: ,_.^
Distribution Method: (7) Equal ❑ Loop ❑ Equal - Hydrosplitter .et Serial ❑ Pressurized ❑ Gravelless Half Pipe
Special Requirements: ❑ Ground water interceptor: Depth: Distance from Drainfield:
❑ Rake Sidewalis .❑ Filter Fabric On Top of Drain Media ❑ Other:
Inspection Requirements: For Pressurized, Sand Filters, RGFs, ATTs and Capping Fill systems, there are several
inspections required. See inspection requirements specific to each system.
The attached Final Inspection Request And Notice Form must be completed and submitted at time of system completion.
For pre -cover inspection information, contact Washington County Environmental Health at (503) 846 -8722.
OFFICE USE: rcv 5/07 ." 4� ® 1* 151 i' f
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Typc of System: `a Fee Received: $7`��+6 D rte `6 e t v Payment Type: 1 { G to CR# j sro I q y
NCR: White copy to Environmental Health Program Yellow copy to Land Use X Transportation (1.U"11 Pink copy to Applicant
G 1ON C
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Health Program
155 N. First Avenue, Suite 160, MS-5, Hillsboro, OR 97124
� Phone: (503) 846 -8722 ® Fax: (503) 846 -4490
ONSITE WASTEWATER TREATMENT SYSTEM CONSTRUCTION
PERMIT ATTACHMENT
Property Owner: APTZI L. O -L.K Permit No: 10 --
RE CAREFUL and BE SAFE — CALL FOR UNDERGROUND UTILITY LOCATIONS BEFORE YOU
DIG! (503) 232 -1987 or 1- 800 - 332 -2344
Special Conditions And Requirements For This Permit
Note: Items are signified with a check mark (✓).
ALL WORK IS TO CONFORM TO OREGON ADMINISTRATIVE RULES, CHAPTER 340, DIVISIONS 71 & 73. WORK
MUST BE DONE BY THE PERMITTEE OR BY LICENSED SEWAGE DISPOSAL SERVICE BUSINESS. MAKE NO
CHANGES IN SYSTEM LOCATION OR SPECIFICATIONS WITHOUT WRITTEN APPROVAL FROM THE PERMIT
ISSUING AGENT.
O A failing system must be repaired as soon as possible. Should the repair of this system be delayed, the permit
holder must notify the agent by phone or in writing the reasons for delay, and propose a different completion date.
Delays may be cause for a formal enforcement action which may result in a civil penalty assessment.
f there are discharges of sewage or septic tank effluent onto the ground surface or into public waters, the permit
holder or property owner must take immediate steps to minimize the threat to public health and the environment.
These steps must include at a minimum:
1. Having the existing septic tank pumped, the outlet plugged, and the tank utilized as a temporary
holding tank until repair of the system is complete.
2. Securing the area of both contaminated and saturated soils with barricades, roping, caution tape
and the posting of warning notices. The notice must read, "Warning — This Area is
Contaminated with Sewage - Please Stay Out" or similar language.
3. Treating the affected area of contaminated /saturated soil with either a calcium carbonate
compound (lime) or other type of sanitizing compound.
O The approved plans for this system call for septic or dosing tank with a "Limited Approval" in Oregon. They are not
to be installed in heavy clay soils or used where a water table would rise above the bottom of the tank. These
tanks come with an installation guide from the manufacturer which is to be strictly followed.
0 This permit is for the installation of an Alternative Treatment Technology (ATT) system. This system is to be
installed only by the property owner that has been certified by the system manufacturer or licensed sewage
disposal business (installer) that has been certified in accordance with OAR 340 - 071 -600 and 650.
D This system includes pumps and electrical components. Verification that these components have passed all
electrical inspections by a certified electrical inspector is required.
Zr Other conditions or requirements: EX ST1 t4,C) tfA-t ML��ES 3Eit44 art Lf Fen Asc
A011.____DgfriguNtE. tS Q Eit4ct _.1. _ _ _ Lt7 o .
NCR: White copy to Environmental Health Program Yellow copy to Applicant tr/t/ r4L4 1 -
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O REG ON
TO: Septic System Permit Holders / Installers
FROM: Washington County Department of Health & Human Services
Environmental Health Onsite Wastewater Program
RE: Your Septic System Construction Permit
Oregon Administrative Rules (340 -12 -170) requires system installers to request a
precover (prior to backfilling the system) inspection when construction, alteration or
repair of a system is complete. To request a precover inspection, the installer or owner
must submit the following:
1. A detailed and accurate as -built plan of the constructed system.
2. A list of materials used in the construction of said system.
3. A written certification that the system was constructed in accordance with
OAR 340 - 071 -0659 and submitted on Washington County's "Final Inspection
Request and Notice" form.
NOTE: This form must be signed by the owner and /or the DEQ licensed installer.
The form must be completed in full and an original signature must be present on the
document. Photocopies or FAX submissions are not accepted. When you are ready for
your precover inspection, submit the form in person or by mail 1o:
Washington County Department of Health & Human Services
Environmental Health Onsite Wastewater Program
155 North First Avenue, MS -5 •
Suite 160
Hillsboro, OR 97124 -3072
Complete forms and return with appropriate fees. If you have any questions, please
contact our office at (503) 846 -8722.
G TON FINAL INSPECTION REQUEST & NOTICE
�`a c ° � Z For Onsite Sewage Disposal System Permits
:4 : Washington County Department of Health & Human Services
`' Environmental Health
°RECON 155 North First Avenue, MS 5, Suite 160 • Hillsboro, OR 97124 -3072
Telephone: (503) 846 -8722 • www.co.washington.or.us
Pursuant to the requirements within ORS 454.655, OAR 340 -71 -175, the system installer and /or the permittee must
notify the Department of Environmental Quality (or it's authorized Agent) when the construction, alteration or repair of a
system for which a permit was issued is completed (prior to the backfilling or covering of the installation). The
Department (or Agent) has 7 days to perform an inspection of the completed construction after the official notice date,
unless the Department elects to waive the inspection and authorizes the system to be backfilled earlier. Receipt and
acceptance of this completed form by the Department establishes the official notice date of your request for a
precover inspection. Please complete this form in its entirety. Incomplete forms will be returned. Note: If a
precover waiver is requested, submission of this form is still required.
;; - PROPERTY OWNER: ,,
Printed Name of Property Owner Permit #
Property Address City State Zip Code
Township Range Section Tax Lot #
Date Form Submitted
MATERIALS LIST -
Identify and list all materials used in the system's construction; include amount, manufacturer size and type. (Example:
40', Acme Mfg., 4" SCH 40 PVC pipe)
9 /9 /2008Revised
AS -BUILT DRAWING OF THE CONSTRUCTED SYSTEM:
Printed Name of Property Owner Permit #
Property Address City State Zip Code
Township Range Section Tax Lot #
Show direction of North, all wells within 200 feet of system, length of each drainline, measurement to tank from two
locations, distances from closest property lines to drainlines and septic tank, dwelling, outbuildings and any
encumbrances.
' 4x to 11 T� . _ . . . _ . . . . . . . .. . . _ . . . ...
?��:+ ekl
SYSTEM CONSTRUCTION COMPLETED BY: •
U Property Owner U DEQ Licensed Installer:
Business Name DEQ License #
1 hereby certify that the information provided on this final inspection request & notice is correct and that
construction was done in accordance with OAR Chapter 340, Divisions 71 and 73.
Owner /Installer Signahire Date
9 /9 /2008Revised