HomeMy WebLinkAboutSWG2022-00603 TANK ONLY - SWG Application / Design - 12/7/2022 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON:360-427-9670,EXT 400
BELFAIR:360-275-4467,EXT 400
Public Health & Human Services ELMA:360482-5269,EXT 400
FAX:360-427-7787
On-Site Sewage System Tank Only Permit: SWG2022-00603
APPLICANT REICHENBACH RICHARD W & BETH A Phone:
Address: 341 SE COOK PLANT FARM RD SHELTON, WA 98584
OWNER REICHENBACH RICHARD W& BETH A Phone:
Address: 341 SE COOK PLANT FARM RD SHELTON, WA 98584
SEPTIC INSTALLER Jerry Upson- MIKKELSEN SEPTIC LLC Phone: 360-480-3571-Jerry
Address: 980 E MIKKELSEN ROAD SHELTON, WA 98584
Site Address: 341 SE COOK PLANT FARM RD
Primary Parcel Number: 320334390020
Permit Description: Replace tank only
Permit Submitted Date: 12/07/2022
Permit Issued Date: 12/07/2022
Issued By: Rhonda Thompson
Current Permit Fees Paid: $240.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 12/07/2023 (based on date of inspection)
Type of Work OSS Repair
Components being Replaced: Septic Tank Only
Surfacing Sewage? No Existing Failure? Yes
Shoreline? No Horizontal Setbacks Met? Yes
Number of Bedrooms: 3 Drinking Water Source: Private Well/Spring
Additional Details: Hagerman 1250 ST
Permit Conditions:
1 Horizontal setbacks per WAC246-272A-0210 must be maintained, unless prior approval is
obtained
4 Proposed development subject to zoning requirements and approval by the planning
department staff per Mason County Title 17.
2 Permit must be installed by a Mason County Certified Installer unless prior written
authorization from Mason County is obtained.
3 Mason County Asbuilt Form, Record Drawing, and Installation fee must be submitted for
final installation approval.
THIS PERMIT MUST BE ONSITE DURING INSTALLATION OF OSS.
PROPERTY OWNERS ARE RESPONSIBLE FOR DETERMINING AND MARKING ALL PROPERTY LINE AND EASEMENT LOCATIONS.
THIS PERMIT MAY BE REVOKED IF THE SITE CONDITIONS HAVE CHANGED SINCE THE SITE WAS INSPECTED AND/OR DESIGN
APPROVED.
FINAL INSTALLATION APPROVAL IS REQUIRED PRIOR TO TEMPORARY OR FINAL OCCUPANCY OF ANY RELATED STRUCTURES.
For Final Inspection visit: masoncountywa.gov/health/environmental/onsiteloss-inspection-request.php or call:
360-427-9670, extension 400.
OFFICIAL USE ONLY
MASON COUNTY DATE RECEIVED: y 1` 71 -
COMMUNITY SERVICES _DB C `)
✓ AMOUNT R6f E.NEQ� r ' RECENED BY: COCn
Public Health (Community Health/Environmental Health) C U)
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al5 N.6th Street�Shelton.WA 985&9 -//�, O
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ON-SITE SEWAGE TANK ONLY APPLICATION › A
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APPLICANT ( c3)
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MAILING ADDRESS-STRE T.CITY,STATE,ZIP CODE l g
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SITE ADDRESS-STREET.CITY,ZIP CODE IrC C `--- rr
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NAME OF DESIGNER PHONE
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NAME OF INSTALLER PHONE v_ `"
c ' rr 013C'r.. 360 4g7 5 -7 // z 11,3
TYPE OF WORK(select one) DRINKING WATER SOURCE O
❑ NEW CONSTRUCTION/UPGRADES tfZEPAIR/REPLACEMENT A PRIVATE INDIVIDUAL WELL 0 PRIVATE TWO-PARTY WELL Z Ij. I
COMPONENT(S)TO BE REPLACED/INSTALLED 0 PUBLIC WATER SYSTEM 1
ONIFPTIC TANK 0 PUMP TANK ❑ RV HOLDING TANK BEDROOMS LOT SIZE Is
❑ OTHER J W 1 ',
OTHER DETAILS(select all that apply) TANK(S)SETBACK CHECKLIST O I�/�)
CI SURFACING
I SURFACING SEWAGEFXISTING FAILURE 0 SHORELINE 100FT+PUBLIC/COMMUNITY WELLS X
SUBMITTALS 50FT+PRIVATE WELLS,SURFACE WATERS,STREAMS.RIVERS
PLOT PLAN(REQUIRED) J4 TANK CROSS SECTION(REQUIRED) 10FT+DRINKING WATER SUPPLY LINES I!�
❑ PUMP DETAILS(IF APPLICABLE) 0 WAIVER(S)(IF APPLICABLE) 5FT+PROPERTY/EASEMENT LINES,FOUNDATIONS,FOOTINGS v
r
PLOT PLAN CHECKLIST O IO
❑ PROPERTY LINES AND EASEMENTS 0 EXISTING/PROPOSED STRUCTURES 0 EXISTING/PROPOSED OSS COMPONENTS AND LINES - -
❑ WELLS WITHIN 100FT 0 WATER SUPPLY LINES 0 DRIVEWAYS/PARKING 0 SURFACE WATERS,STREAMS,RIVERS,ETC... Ic 3
❑ DIRECTION OF SLOPE/CONTOURS ❑ PERIMETER/CURTAIN DRAINS 0 NORTH ARROW 0 SCALE BAR
`,
DIRECTIONS TO SITE AND SITE CONDITIONS:(ex.locked gate) -✓
D O dC
DEC 0 7 2022
By
OFFICIAL USE ONLY BELOW THIS LINE
UPGRADE!FAILURE SOURCE(for reporting purposes)
❑VOLUNTARY 0 MAINTENANCE/PUMPING 0 BUILDING PERMIT CI HOME SALE ['COMPLAINT 0 OTHER:
COMMENTS I CONDITIONS
QM\GLQt VC n V- S A n--e_\ Ocx/ttwn
SEWAGE TANKS MUST BE LISTED UNDER DOH"LIST OF REGISTERED SEWAGE TANKS". TANKS MUST MEET CURRENT MINIMUM SIZE REQUIREMENTS.EQUIPPED WITH RISERS
AND LIDS TO SURFACE,AND INCLUDE AN EFFLUENT FILTER(IF APPLICABLE). RECORD DRAWING AND INSTALLATION REPORT REQUIRED FOR FINAL APPROVAL.
INSPECTOR SIGNATURE DATE APPLICATION EXPIRATION DATE APPLICATION APPROVED/ISSUED BY DATE
--------. VL I 1 IT 4) LIDC\CLAI VO .24-7(1 7_,_
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE REVISED 12/712015
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APPROVED
DEC 0 7 2022
MASON COUNTY ENVIRONMENTAL HEALTH
RET
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HAGERMAN PRE-CAST
1 • Bob&Anita Hagerman
PO Box 2842
Pouktw WA983711
360-598-6121/360489-3702
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MASON COUNTY ENVIRONMENTAL HEALTh
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