HomeMy WebLinkAboutEx15_Septic_Abandonment_ReportReport 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:
EXHIBIT 15
10/15/25MKerrihard
PLANNING DIVISIONRECEIVED
1 0 2 3 0 5 9 1 1 7
4508 NE 4TH ST 98059
ESTATE HIGHLANDS LLC
4
4
4
Unknown work confirmed by Uniform Plumbing Company, LLC (see attached report).
Unknown (historic abandonment).
4
Existing septic tank was decommissioned prior to current ownership. Exact date and original pumper
information unknown. Based on Uniform Plumbing Company inspection and sewer camera report (dated
8/11/2025), the septic system was abandoned and removed, and the property is currently served by public
sewer. Documentation provided herein is to regularize with City requirements.
Docusign Envelope ID: FFB6F336-7B75-4DAC-8020-35E8974E808F