HomeMy WebLinkAboutSeptic_Abandonment_Report_4508NE4th_Renton.pdfReport of Wastewater Tank Abandonment Revised 2/8/2023
REPORT OF WASTEWATER TANK ABANDONMENT
Instructions for completing form: This form is to be completed by any persons permanently removing a
septic tank, seepage pit, cesspool, or other on-site sewage system wastewater tanks from service. Complete and submit this report to the health officer within thirty (30) days of the abandonment. Authority: Chapter 13.04.054, the Code of King County Board of Health, Title 13.
Submit form either: -By mail to Eastgate Environmental Health 14350 SE Eastgate Way, Bellevue, WA 98007-6458-By email to EHOSSInformation@kingcounty.gov
Abandoned Date:
General Property Information (Please print):
Parcel Number (10 digits):
Site Address:
Name of Owner/Occupant of Property:
Pump Tank Holding Tank Other:
Wastewater Tank Data:
Type of Sewage Tank: Septic Tank
Number of Compartments Pumped:
Number of Gallons Pumped:
Checklist Item Yes No Not Applicable Comments
Septage removed by an approved pumper?*
Tank lid removed or destroyed?
Tank void filled with compacted soil or gravel?
*OSS Pumper Name:
King County Certification Number:
Reason for wastewater tank abandonment: Property being served by public sewers
Property being served by replacement tank Structure being demolished
Comments: