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Septic System Cost Share Program (2022-2023)

  1. For full details, visit:
  2. HOUSEHOLD SIZE DOCUMENTATION REQUIRED

    Please list each household member’s name, date of birth, and annual income. Include Applicants.

  3. For individuals 18 years of age and over, please submit photocopies of the following to verify identity: 

     

    • Social Security Card

     

    And one of the following:

     

    • Photo ID
    • Medical Card
    • Birth Certificate

     

    For individuals who are under 18 years of age, please submit a photocopy of one of the following to verify identity:

     

    • Social Security Card
    • Medical, legal, tax or education document displaying full name and social security number

     

  4. INCOME DOCUMENTATION REQUIRED


    1.  Two years of Tax returns for applicants must be provided.
    2. Two months of bank statements, showing income receipt.  

            AND,

    1. All household members must send proof of income in the following form:

     

    • Earned Income: Pay stubs or W4.

     

    • Unemployment Compensation:  Pay stubs or an income print-out from the unemployment office.

     

    • Social Security, VA benefits or pension:  Determination letter or bank deposits print-outs
  5. Mail or drop off* household size documentation and income documentation to:

    Jefferson County Public Health
     c/o Amanda Christofferson
     615 Sheridan
    Port Townsend, WA 98368

    *Open Mon-Fri, 9 am – 4:30 pm.

  6. I/We hereby apply for the cost share described in this application. l/We certify that l/We made no misrepresentations in this application or in any related documents, that all information is true and complete, and that l/We did not omit any important information. l/We agree that any property undergoing repair will not be used for any illegal purpose. l/We understand that the Cost Share provider may retain this application and any other personal financial information Cost Share provider receives, even if no cost share is granted.  These documents will be retained under secure procedures for the appropriate retention period.


    By typing my name above, I agree to the terms listed above.

  7. I/We hereby apply for the cost share described in this application. l/We certify that l/We made no misrepresentations in this application or in any related documents, that all information is true and complete, and that l/We did not omit any important information. l/We agree that any property undergoing repair will not be used for any illegal purpose. l/We understand that the Cost Share provider may retain this application and any other personal financial information Cost Share provider receives, even if no cost share is granted.  These documents will be retained under secure procedures for the appropriate retention period.


    By typing my name above, I agree to the terms listed above.

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