HomeMy WebLinkAboutSWG99-0439 - SWG Application / Design / As-Built - 11/22/1999 MASON COUN-r4 DEPARTMENT OF HEALTH SERVICES PERMIT NO. SWG N
. • {{ a fD
426 W. CEDAR 7 P.O. BOX 1666/SHELTON, WA 98584
Date
PHONE (360)427-9670 Receipt � y
-' Amount$ Z f
m
P PERTY O NER: ATE: CHECK APPLICABLE ITEM �/ 3
M LIAI�`DDRESS:�t 5 NEW SYSTEM
(/ AYTIMEPHONE: REPAIR SYSTEM
/30 b TABLE 6-REPAIR m
CITY: ZIP:
STATE: MAINTENANCE REVIEW m
P OPERTY ADDR SaS: s SINGLE FAMILY a
` / 8 OTHER: 3
PRIVATE WELL m
SPECIFIC[))RVJTIONSFORLOCATING ITE: Ariyl'��ftb.57 3a�,7, �A COMMUNITYWELLIPUBLICSYSTEM
SYSTEM WFI p C?j
SYSTEM NAME p,
�v APPLICANT 7
" I,vc NAME IAA!
Name of Lot ft.x—ft. MAILING ADDRESS �0 ,C /L3 I W
Installer lx5 O W
Size: (p�C�!= acres TELEPHONE .D K `
Name of k/I �,G C � Number o 2 SIGNAT
Designer Bedrooms Ix
OFFICIAL USE ONLY BELOW THIS LIN I `y
DEPARTMENTA?OIL LOGS DEPARTMENTAL COMMENTS/CONDITIONS I 1—
�Jr 0-2 q f41L 7'+43 � to
0-3 2 G s� w �✓ 10
v5� 3Z- G3 GrLfo
wI1;Jrn� to
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Yz. - 7r J%
SOIL TEXTURE,CODES:
V=Very G=gravelly S=sand L=loam Si=silt C=clay E=Extremely
INS CTOR(print nam IP6PE&I9N SIG E DATE PERMIT EXPI TION ATE
IZ is in I
•All systems r uire ongoing Aeration and Maintenance(08M)asspecified in Mason County On-Site Standards.
•All on-site sewage systems must be designed by a Mason County Certified Designer or a Professional Engineer,unless prior approval is granted otherwise
•All on-s@e sewage systems must be installed by a Mason County Certified Installer,unless prior approval is granted otherwise.In such cases a preliminary on-site
meeting between health department staff and the homeowner is required.
•On-site sewage system design approval does not imply other building site requirements(i.e.RLC,Water Adequacy)have been met.
•Any change from the specified use of the property or any site alteration affecting the system design may invalidate this permit.
•This permit
expires 3 ears from the date of site review.Denial of this permit may b�appealed to the Health Officer within 10 clays of deni data.
DESIGN REVIEW APPROVAL BY: DATE: IN TION APP VE l DATE:
TOP: Health Dept. Copy MIDDLE: Designer's Copy BOTTOM: pplicant's Copy
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MASON CO ;
DEPARTMENT OF HEALTH SERVICESJ.
"
Environmental Health Water Quality Per anal Health
PO BOX 1666 SHEL7 N, WA 98584
LOCAL 06)427-9670
BELFAIR(206)2 -4467&4468
FAX 06)427-1798
DATE: Z /lS ) 9
TO: Lo��T� 11J w
FROM: /Qy`
RE: Design for_ ,-o 4 -w (�O Parcel U O U
Your design for the above referenced parcel has been reviewed and is APPROVED.
L�
Your design for the above referenced parcel has been reviewed and is
NOT APPROVED. Itdoes not meet the requirements or needs additional
information.
DESIGN FORM - PAGE ONE Revised April 24,1998
A design will'be reviewed when 33 copies.of each of the following items are submitted:
Completed design form that has been signed and dated a Scaled layout sketch,Including all applicable Items on checklist
% Scaled plot plan,including all applicable Items on checklist a Cross-section sketch,Including all applicable ite son checklist
PARCEL IDENTIFICATION
Permit Number: S WG Designer's Name:
Designer's Phone#: k 7 7- 9 ✓r 9'
Applicant's Name: �3ROGfl �RUJL ; SS Assessor's Parcel - - GO U
Mailing Address: ✓O g '?l /053 (Cwdve-Di it Number)
/fGG[�S.�GRT %/ ?�� Subdivision:
city Statc zip (Name/Divislon/Btock/t-ot)
DESIGN PARAMETERS.
r1 Treatment Device !�
O Glendon Biofilter � O Sand Filter O Mound /'/ O Sand Lined Drainfield
O Aerobic Unit-Make/M del: -- O Disinfection U it - Make/Model:
Drainfield Type
O Pressure O Bed O Drainrock
Gravity 04 Trench a Gravelles Chambers
Septic Tank/Drainfield Specifications Laterals
Number of Bedrooms 3 Schedule/Class a5 t i ,Z7 9
,�I�
Daily Flow 3 o p .. (,% d Length : 75 ft
Septic Tank Capacity Diameter 1.VF0-Md 7-O R in
-3
Receiving Soil Type(1-6) ft
Receiving Soil Appl.Rate ft! Number Separation
Required Square Footage ft, Orifices
Designed Square Footage Total Number of Orifices
Percent Reduction Taken °�L' Diameter in
Trench/Bed Width 3 $ P in
TrenchBedLength (�R. 75 frl. Spacing
ldn Coun:.y Dept. iieslt
Elevation Measurements A
Schedd7!(RP ROVED ,
Original Drainfield Area Slope Z % Length ft
New Slope if Altered j, % Diameter Initials \ in
Depth of Excavation from I Z-//I � y
Original Grade /6 /'f in Preferred 1�Idfold�unflgliLraCtodUsed? Yes ❑No
/2 /(f) slope)
in Transport Pipe
(Down--slope) Schedule/Class 5��49 ,
Designed Vertical Separation J 4 i1/ in Length 3no ft )
Diameter in
Gravelless Chambers Required? ❑Yes ❑No Optional
Pump Required? ❑Yes No Dosing and Pump Chamber
Number of Doses/Day
Pump/Siphon Specifications Dose Quantity cal
Difference in Elevation Between Pump Shutoff and Uppermost Chamber Capacity gal
Orifice: ft Pump Controls: Timer(or) Elapse TimeMeter(circle if required)
ff
If Timer: Pump On Pump O
Uppermost Orifice is❑Higher, ❑Lower than Pump utoff `
Capacity @ Total Pressure Head: t m Check the followiW156mponents if they drain between doses:
Calculated Total Pressure Head: L ❑ Laterals 0 Manifold ❑ Transport .
(Attach Pump Curve) `
C
c <T
DESIGN FORM - PAGE TWO Revised April zo, 1998
DESIGN CHECKLISTS'
Scaled Plot Plan Scaled Layout Sketch Cross -Section Sketch
Test hole locations 0 Drainfield orientation and layout Referenced depth rom original grade:
Property lines � Trench/bed dimensions and critical 0 Septic tank lid d drainfield cover
jtI Existing and proposed wells within distances within layout depth
100 fir of property lines 0 D-Box/"T'/"L"locations
JS Critical distance measurements to cuts, fA Septic tank/pump chamber location Reference depth from original grade
banks,and surface water Jx Observation port location and restrictive str ta:
0-Location and orientation of curtain Ja Clean-out location )I Laterals,trench bed top and bottom
drain and all absorption components 9-Manifold placement -Q-Curtain drain collector
Location and dimension of primary Orifice placement a-Sand augmentation
system and reserve area $-Lateral placement,with distances to
Q Buildings edge of bed Other cross-sectio detail:
fl Direction of slope indicator Audible/visual alarm referenced kM Observation ports and clean-outs
0 Waterlines Q Scale of drawing shown on scale bar
Roads/easements/driveways/ r —
iCfoss section in orafation for mound
parking Layou\nformation for�oirnd system isystem:
Critical resource lands(if applicable) O Overall-fit dimensions IO Settled cap dep at center and edge p£
J19 North arrow and scale of drawing 0 Up-slope do*nslope,and endslope j bed
shown on scale bar fill width ip Sidewall slope
D Up slope and do ffHlo e.bed elevation
Additional Information
J 4 Design staked out
`f2 Operation and IviaiDwnance Notice
ached
O WaiveT(sZ Attached
DESIGN APPROVAL
The undersigned designer❑does, Cl does not,waive the Eire t to be notified by the installer of the installation and given 48
hours to perform a final inspection prior to cuy
o
---Signature Designer Date
The undersigned has reviewed this design on behalf of Mason County Department of Health Services and determined it to be in
compliance with state and local on-site regulation:
Environmental Healthlsl� Date
T�
Caution: DESIGN APPROVAL IS VALID ONLY UNDER THE FOLLOWING CONDITION:
✓ The design is stamped"Approved"by Mason County Department of Health Services.
✓ The On-site Sewage Permit has not expired, the Permit Expiration Date is: I Z. JT/D-2_
✓ The system is installed by a certified installer,unless prior authorization is obtained Mason County
Department of Health Services.
J Drainfield site conditions have not been altered to adversely affect conditions of design approval
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APPROVED �O
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APOVED f ' 51,
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APPROVE
4.+� Ei iiil it Initials Cam— Cl
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--L' -' Date 12 i
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Mode: INQUIRY REAL PROPERTY
Parcel # .32331 22 00000 Rng 3 Twp 23 Sec 31 Tax Yr 2000
Taxpayer # TAHJ 3100 TAHJA, ARNOLD H T/P Chg Dt 12/29/1998
Title Owner # TAHJ 3100 TAHJA, ARNOLD H T/P Chg By WBS
Contract' Owner # Loan #
Plat/Condo Type Code Blk Lot Unit Dock
Description GOUT LOT 1 EX AssocM/H
Chg Dt 12/29/1998
Chg By WBS
Chg Rs RV
FS 00405 :
Tax Code 0315 1 404 P1 F1 L H Land Use 9115 VIEW < SIC
Zoning Code Tax Stat TX TAXABLE li Reval 3
Chg Rs F/P? Y Ac
Land: Improved Unimproved Timberland Total Land Improvem4nt Total AV
Acres
Taxable 35, 000 35,000 35, 000
Market
New/C 0/AV Mob Home AV Sub Cd Ints
Sr Cit Cd Reg Exmpt O/R Regular Taxable 35, 000
Lien Date AF # As-Tx Yr App # Agr #
Inquiry Type VL HELP Cmd Keys : 1, 2, 6, 7, 9, 11
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029 18"Z6£1
ON-SITE SEWAGE INSTALLATION
FINAL INSPECTION
DATE CALLED IN: -
TIME: �n
INSTALLER:
APPL.LCANT/OWNER:
CALLER: l �C
PHONE#OF CALLER:
PARCELNUMBER: � c
SUBDIVISION:
Div: Lot
SYSTEM TYPE(CHECK ONE):
PRESSURE GRAVITY
INSPECTION SCHEDULE(CHECK ONE): /ley'
APPONiMENT PLU0IN
AS-BUILT ON-4ITE(CHECK ONE): n
YES IT
STAFF INITIALS: -
"��"a:,y\�,"q,•sixrYiS� sx .. ..h„ �.s". .Yx�a � 7E;�I+�I.`"�`_i s3 »*.sic �� $-v�'kR�����o � ' \mc
APPOINTMENT DATE: `� S /O Z TIME: l o „`, ,3 0
COMMENTS:
r
ON-SITE SEWAGE INSTALLATION
STAFF INSPECTION REPORT
.'rL-ixiz•'.<'1•k:z: ..-.4..:y.n$ �h4.-.. a;: .t;. . "� g': t.rc ,.w e... 2^41���. .0
Yes No Comments
L SEYRC TANS
A) >5 ft.from foundation?
B) >50 ft from wells and surface water?
C) Bldg stub-out to septic tank:clean-out if not I-2°/a7 �G
D) Baffles intact and clesa? �G
E) Dividing wall intact?
F) Risers installed for access?
IL D-Box• Leveled wiV'Z�and/or speed leveler(circle)?
III DR&DMZ2D
A) >10 ft fmm foundation and>5 ft from perceived property lines? _I
B) >100 ft from wells and surface water'? _11�
C) >10 ft from potable water lines? JG
D) Laterals level to±1 inch&end caps present if not looped?
E) Gravelless chambers utilized? —
F) System dimensions the same as shown on the design?
G) Gravel clean,properiy sized,and proper depth? —1G
H) PREss W SvSTna
1) Sand qualityASTMC-33?
2) Head height uniform and z24 inches? _
3) Clean-outs and observation ports present? _
4) Mound Side Slope 3:1? _
5) Owner informed electrical connections must be made _
by owner or licensed electrician and inspected by TAM
IV. pUW1PrnW CUAMBM
A) Screen basket or of neat (circle one)installed?
B) Riser installed for access?
C) Alarm installed?
D) Pump on Lima or demand(circle)?
V. AS-BumTREQunw?
VL OTHM Coa'rtvDNWOBSEB-VATIONS
The undersigned has reviewed this installation and verifies these findings on behalf of Maso County Department of Health Servi
,4 y� Z
Sanitarian Date
C:V.tyFdctlwlchc&-%pd
Aevised9l2"7
RECEIV .:D
AS-BUILT FORM RCviS0dJ==y4,1999
........... .............. ........ .
.............
.......... .......
.. ..... . ...... .
.. .......
.... ... . ....
Inn_, PAR13E4ID1rNTiF1CATlON
Applicant La
Assessor's
Parcel#
Permit Number SWGqR- 00qfLC�_ (Twetve-Digit umber)
Installer -4�roL) L_� Subdivision (Name/Divisloiglock/Lot)
Designer
.......
WSTALI;WC
Emffix
N/A Yes Prior to Completion
I QSEPTICTANK 0
A) >5 fL From foundation? ... ........ . . . ...... ... ... . .. . . .... ..... ..
❑B) >50 R from wells and surface water? .. .. ... . . ... . ... ... . . ... . ... . ..
Q Bldg stub-out to septic tank:clean-out if not 1-2%? . . .. . .. . . . .. . . ... . .. ❑ 0
D) Baffles intact and clean? . . . ........ . . . . .. . . . . . . . . . . . . . . ... . ... . . . ❑ 0
E) Dividing wall intact?. . ... . . .. .. .. . .. . . . ... . . .. . . . . . . . . . . ... . .. . .. ❑ 0
F) Risers installed for access? . . ...... .. . . . . .... . . .. . . . .. . . . . . . . . .. . . . D 0
G) Tank Size: W gal.;Manufacture
11. D-Box
A) Leveled with water? . . . . . . . . . . . . .. . . . . . . ... . . . . . . . . . . . . . . . . . . . . . .
B) Speed leveler used? . . . . . . . . . . . . . .. . . . . . . . . . . .. . . . . . . . . . . .. . . . . . . 0 0
III. DRAINFIELD
A) >10 ft from foundation and>5 ft from property lines? . . . . . . .. . . .
0 ❑
B) >100 ft from wells and surface water? ..... . ... . . . . . . .. . . .. . . . �� : 11 0
Q >10 ft from potable watef lines? . . ...... . . ..... .. . . . . . . .. . . .. . .... . 0
❑
D) Laterals level to±I inch&end caps present if not looped? . . .. . .... 11 ❑
E) Gravelless chambers utilized? . . .............. . .. . .... .... .... .... . 0
❑
F) System dimensions the same as shown on the design?.. ... . ..... . ... . ... D ❑
G) Gravel clean,properly sized,and proper depth? .. . .. . ... . .... . ... . ....� 0
❑
H) PRESSURE SYSTEMS 0 0
1) Sand quality ASTM C-33? ... . ...... . .... . .. . .... .... . ... . . . . .
2) Head height uniform and z14 inches? Actual head height... . . .. . 0
❑
3) Clean-outs and observation ports present? .. . . . . . . . . . .... . I * * I , *I *.,,;J01 0 E3
4) Mound: SideSlope3:1? . . . . ...... . . .. .. . . . . .. . . ... . . . .. . .. . . 13 0
5) Owner informed electrical connections must be made 0 0
by owner or licensed electrician and inspected by L&I? . . . . . .
IV. PUMPIPUMP CHAMBER
A) Screen basket or effluent filter(circle one)installed? .... . .... . . .... ... .
B) Riser installed for access? . ...... . . ..... . ... . ... .... . ......
, ❑
C) Alarm installed? ... . ... . . ... .... .. , " 0 0
.. . ... . . . . ..... ..
D) Pump make Pump model
E) Chamber size ��r gaLfinch; Chamber Manufacture
0 0:
F) Pump chamber_&wW44 wn_ inches per minute; Height of pump off 1%6�Uom of pump chamber inches
G) Pump controls:Timer(or)Elapsed Time Meter (circle If Installed); If timer is used:Pump On __Pump Off
AS-SUILT C1RAWING .. .........
.........
.................
.........
.............
CnEmLisr
Drainfield&manifold
orientation &layout LJ
Trench/bed dimensions
and critical distances
within layout
Septic/puunp tank
placement..
Location of buildings.
r4 Observation port&clean-
out location.
Location of wells&
roads.
Undisturbed native soil
between trenches.
X—North arrow 0
CAUTION:Minor adjustments to septic tank location and drainfield orientation made in the field by the installer are generally acceptable to both the�te%meid
and could in certain cases compromise the viability of the system. It is the installer's responsibility to obtain prior written approval from either the
It deparhnent or the designer before making any deviations from the design that affect the system viability. Any deviations from the approved design must be
shown above.
LLATIfJ;N
AGI��GATION PFINSTA
. ... .... .
Installer Check a box from Row"A"and"B",sign and date the certification
A. 0 1 certify that I installed the system without any El I certify that all deviations from the design stamped
deviation from the design stamped""PROVED"by "APPROVED"by MCDHS are shown above.
MCDHS
B. 0 1 certify that I contacted the designer and left the Q I did not contact the designer prior to final cover because the
system open for inspection up to 48 hrs prior to designer waived the notification requirement.
cover.
I further certify that all information contained on this form is accurate. I understand that if the info
n pion contained herein is not
accurate,there will be just cause for immediate suspension of my installer certifirAdon.
dam
------r)7—atlre of Ioffiler ate
The undersigned approves this installation on behalf of Mason County De"ment of 717thirvices/ r
Sanitarian Date