HomeMy WebLinkAboutSWG2002-00373 - SWG Application / Design - 9/6/2002 MASON COUNTY DEPARTMENT OF HEALTH SERVICES PERMI NO. SWG 2UU Z�0037.3
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Date
426 W. CEDAR/ P.O. BOX 1666/SHELTON, WA 98584 5
PHONE (360) 427-9670 Receipt No{ -7 Z
Amount$ y �
PROPERTY OWNE N 1 DATE: CHECK APPLICABLE ITEMS 0/
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'Ob r NEW SYSTEM
MAILING,ADDRESS: YTI� 3 NE7 a - . �.
REPAIR SYSTEM
.T TABLE 6 REPAIR m
CITY:-�� STATE: �� ZI ��S MAINTENANCE REVIEW m
' "A t `, /- SINGLE FAMILY c
PROPER ADDRESS: �kJ�P OTHER: 3
SPECIFIC DIRECTIONS FOR LOCATING SITE: I PRIVATE WELL m
7, e 5 COMMUNITYWELL/PUBLICSYSTEM L
'L �1} f SYSTEM WFI N I�hf
t cat Y /'L e7 l �J e cC,05 J SYSTEM NAME Ip ,
APPLICANT ITV
NAME I—
Name of Lot ft.x ft. MAILING ADDRESS
Installer J 7� �' 4 W
Size: 1J i a acres TELEPHONE S I�
Name of SIGNATURE
Number o
Designer �j Bedrooms X
OFFICIAL USE ONLY BELOW THIS LINE 1 '
EPARTMENTAL SOIL LOGS DEPARTMENTAL COMMENTS/CONDITIONS 11�!
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SOIL TEXTURE CODES:
V=Very G=gravelly S=sand L=loam Si=silt C=clay E=Extremely
NsffcTOR(p t na )P6S`PECTl9N SIGN U��++E D TE PERMIT EXPIRATION DATE
w (,.�urlea ai a �i d6
•All systems re#re ongoing Operation and Maintenance(O&M)as 6pecified 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-site sewage systems must be installed by a Mason County Certified Installer,unless prior approval is granted otherwise. In such rases 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 yipars from the date of site review.Denial of this permit ma be eal the Health Officer within 10 da s of denial date.
DESIG EVIEW APPL DATE: INST LLATI APP BY: DATE:
c bl 1,71a3
S ZI 0q
TOP: Health Dept. Copy MIDDLE: Designer's Copy TTOM: Applicant's Copy
MAISON' COUNTY
DEPARTMENT OF HEALTH SERVICES
March 03, 2003 PO BOX 1666 SHELTON, WA 98584
SHELTON (360)427-9670
FAX (360)427-7798
HasBrouck Design Services ELMA (360) 482-5269
460 W Deegan Rd W BELFAIR (360) 275-4467
Shelton WA 98584 SEATTLE (206)464-6968
RE: Design for BINION
Case No: SWG2002-00373
Parcel No: 321364390100
Your design for the above referenced parcel has been review and is APPROVED.
Please refer to the comments section of this letter for any additional information.
Please call me at(360) 427-9670, ext. 353 if you have any questions.
Sincerely,
Cindy Waite
Environmental Health
Mason County Health Services
COMMENTS:
3/3/2003 1 of 1 SWG2002-00373
MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
Environmental Health Persona ea th
PO BOX 1666 SHELTON,WA 99584
LOCAL(360)427-9670
(360)427-7798
Application for Waiver/Appeal Sip cFj�
F
Amount Paid: QZ6 OU , O
i
Receipt Number: CFO�R
Instructions ST
1. " Complete Parts 1<and 2. No determination can be made until these parts are fl(y�c no 1pletad,
2' Fees may be billed for waivers and appeals,based on the environmental health fee schedule.
3. Submit completed application,
with attachments to the health department for review.
PART 1: Applicant/Parcel Identification
Name of Applicant -! r` Date 3 d �
Mailing Address 5 �� ( — �D q� ' S LJ Telephone °' �3 "d7-1 �--
CA h A4 I /T �l V�L v
Assessor's Parcel Number
Subdivision Name and Lot
PART 2: Nature of Waiver/Appeal
❑ On-Site Sewage Requirements ❑ Food Sanitation Requirements
❑ Building permit review policies ❑ Solid Waste Requirements
❑ Location, WAC 246-272-09501 ❑ Group B Water System Requirements
❑ Holding tank WAC 2 46-2 72-12 5 01 ❑ Water Adequacy Requirements
On-Site Standards ❑ Enforcement Timelines
❑ Certification contractor(pumper, ❑ Departmental Determinations
designer, installer, O&Mspec) requirements ❑ Other
Description of Waiver/Appeal(include justification, additional material may be attached):
�Ve " 2- J'l e 7 doh r e 10 Arerr�
he95vrL +L ri�� cr , /cPlJc Sr is nP/171JS3n
l
Applicant Signatur
Date:
/I.IWDATAURCHIVEIWAIVER.WP Update:November 23,1998
PART 3: Health Department Evaluation (Staff Use Only)
IA. Type of Determination Required: 1 B. Type of On-Site Waiver(if applicable):
❑ Appeal Waiver ❑ None required ❑ Class A Ieclass B ❑ Class C
2. Identificaton of Specific Code/Standard/Determination(include date of determination or latest
code/standard revision):
ayd -;Y7Z-
3. Nature of Appeal:
rR,e > ICa� ,rt,2Pn Z rr C LaC. o /OitR¢o u�/
4. Hearing Official:
❑ Board of Health ;.Health Officer
❑ Pollution Control Hearing Board ❑ Health Services Director
❑ Certified Contractor Review Board ❑ Envirortmental Health Manager
5 Mitigating Factors:
6. 1 have reviewed this waiver/variance request. 1t is complete, and mitigation required by state and local
policy has been submitted.
Staff: ��°�' t/" Date: Z 2 I 0
PART 4: Determination of the Hearing Official
/ The hearing official has determined that approval of this request will not adversely affect public health and
is hereby granted. This decision is based on the following findings and conditions:
❑ The hearing official has determined that approval of this request could potentially have an adversely affect
public health and is hereby denied. This decision is based on the following findings:
Hearing Official i�i�/'G•!aGfil..r'XC�OQ-t! Date.vazl__6_2�>
II:IWDATAIARCHIVEIWAIVER.WP Update:November 23, 1998
APPENDIX A
CLASS B WAIVER OF ON-SITE SEWAGE REGULATIONS WAC 246-272
AND
WORKSHEET FOR DETERMINING A REDUCTION IN VERTICAL SEPARATION
This wotksheet is used to determine if a site qualifies for a reduction in vertical separation under the Class B Waiver. Please fill out
the worksheet in its entirety. Incomplete worksheets are returned to you and will cause delays in your permit application.
Part 1:Applicant Information p/
Name of Applicant: b r r-- Date:
Site Address: d Q
Mailing Address: .�22 � — D D �� � 1 � 'L S � d
City: (� ham.0� F� State:�4_ Zip: 0 S
Assessor's Parcel#: / LI ? L?fl) 0 SwG#
Part 2: Checklist
1) Son Series 3) Check the son structure. �
� '�'¢j�g..'� ��:•�,•yx - � e at1�3��45G � � t@ ���,. ya 4 o°°T"
a
Single"ed or weak ........................
'`.`s.. e..l. ❑
Well structured ............................... .:.
AWaaood Gravelly Saud Loam ................. ® other ...•.
Hmsdoe(hardly Saud Loam ................... (3 4) Cheek percent slope of the primary/reserre dralatield
Hoodspart0111Ity Sod Lamm.................. ❑ area.
SheltonOraredy Sand Loam ....... ............ (3
Silelair Graven Sand Loam .................... Cl OEM=
Od. ........ ❑' :
2) Chock the son type: Less dim 3% ................................ �E3
3%-IS% ................................... ts�s
16%-30% .................................. (3
. . Greater than 30% ............................. ❑
6) Chock the up-slope vertical se aratioa.
Loam ...................................... ❑ W
Lawny Sand • ••
Sandy Loam ............ , ................ ku a v :. a o: Xe
Percent Gravel by Volume: ;T
Lessthan erequal to 60% .................. Less than it ................................
,a
(kcdw d=60%......................... ....xa 12-I9" ....................................�
Greater don I8" ......... ❑
Determined br.
Depth to Hardpan .........................
Depµ to Modeling
r
Both .................................... ❑
6) Cheek the dralua a of the soil. lox) Check Horizontal Attenuation Zone.`
is there less than 50 fed between the down gradient side of
Well Drained ................................ ❑
the proposed primary and reserve drainfiekl areas and the
property bomdary?
Moderately Well Drained.......................
Yes ........................................ ❑
Other ❑
No.........................................
7a)Check water table kveL if yes,the applicant will need to provide a recorded
covenant or easement prior to final acceptance of the on-
site sewage Application.
a "'? x 10b) Record 50 foot zone on deed. ,EsZ
is the water table: a w x»
Above36" ..................................
Above24. .................................. ❑ c a
Abovel2" .................................. ❑ V.
o E
76 Is a curtain drainproposed u slo of the rime x :'
P Pe P ry h Is the owner awacr�anagreement with then tams?
drolafield area? (home owner initi )
Yes ......................................... ,.
Yes ........................................
No.......................................
8) L the ro err on marise shoreline? :?
Is the 50 zone recorded on the deed? ?.
a
z
o,,, el ❑.w Yes ........................................
No.........................................
Yes ........................................ ❑ 11) Check proximity to wells.
No......................................... '
if yes,Wic�w the distance from the shotdiae to primary
draiotleidmoa fed
9) Are{hero nay fresh water bodies within,or adjacent to. Indicate the smallest distauoe from existing or Proposed wells to the
the pro primary or reserve drabrfieid areas. Biz fed
' V
Yes ........................................ 0
No........................ 0..............
if yea,ve itdiatedistonoe from shoreline to primary& .. ..,
reser aaav
Designer Comments:
x
Part 3: Certification and Approval
Applicant Certification:
I certify,to the best of my knowledge,that the above information is true and cortecL I acknowledge that I am solely responsible for maintaining the
integrity of the primary and a dramfield areas;and that destruction or damage to the drainfield area may result in immediate rescinding of the
onsite sewage it
Z
r Date
r 4 'T/'�j Z c,
Date
App rcant
Health Department Review:
Preliminary Review For Design Submission: ❑Approved ❑Denied
Environmental Health Sanitarian Date
Waiver is 0 Approved ❑Denied
Environmental Health Sanitarian Date
Comments:
RECEIVED
DESIGN FORM—PAGE ONE SEP 0 6 1meary 4.1999
A design will be reviewed twhhen 3 copies of each of the following Rams are Aubmittedapd�W Wear*
awled plotwk
lnoir
t�udlnRp itl apq enleebbdMemaon eMeWlet C�rosi�eaeU n sketch. I�pitl�pplbabkN RReeme�on�oTidMA�t
PermRNumber: SWG oo373 Designer's Name.
�
t Designer's Phone P: Z 114R/ q,37/)
Applicant's Name: >f J eb ram 5 + " tort Assessor's Parcel No.: �al z
Mailing Address: a 4 Q+,)-g l (ta<t a otstethettbed
Subdivision:
Calf state Up (Nunr/DivbbnlBletir/faQ .
Treatment Device
0 Glendora Biofilter O Sand Filter 0 Mound O Sand Lined Dtainfield
0 Aerobic Unit-Make/Model: O Disinfection Unit - Make/Model:
Drainfield Type
® Pressure O Bed O Dminrock
O Gravity .9 Trench iD.Gravelles Chambers
Septic Tank/Dralnfield Specifications Laterals
Number of Bedrooms 5 Schedule/Class
Dai Flow 3 C O cod Leos
Septic Tank Capacity eai Diameter
in Receiving Soil Type(1-0 Number
Receiving Soil Appl.Rate ¢od/t Separation 1 yn ft
Regoired Square Footage Orifices
Designed ST=Footage (o / I7
Peroat Reduction Taken �— % Total Number of Orificesin
to
D
ThinchIBed Width ; _ R Diameter
Tin nda/Bed Length 2/9 Lf, 7 h ft Spaci�p p ROV E
MC H@ACTH DEPT
Elevatlorl Measurements ���� - anBoid
S.lu:.1dal l 3 200
Original Drsinfield Area Slope 3 7 % Len
gth
New Slope If Altered /e Diameter
cew in
• e
Depth of Excavation from - / / „ [a in Preferred Manifold Configuration Used? Yes ❑No
original Grade (u"10x)
)M1 I +71 in Transport Pipe L�
(Dow Tope) Schedule/Class
Length / T R
Designed Vertical Separation in Diameterin
Gtavelless Chambers Required? 'M Yes ❑No O Optional Dosing and Pump Chamber
Pump Replied? Yes ❑No DoseNum Q ai Doses/Day PumpOphon Specifications Dose dty
ChamberCepaeitygal
Difference in Elevation Between Pump Shutoff and Uppermost Pump Controls: Timer(orl Elapse, Meter(ahela ffrequhad)
Orifice: R If Timer. Pump On Pump.Of
UWa aoat Office is 0 Higher, (9 Lower than Pump Shtrto . Cheek the following components if they drain between doses:
Cr pad y q j Total Pressure Head: ✓ 13 Latetdls (3 Manifoid 0 Transport
Calculated TOW Pressure Had: 3 ft
(Atmch Pump Curve)
DESIGN FORM-PAGE TWO RavhalAptlst.19"
Scaled Plot Plan Scaled Layout Sketch Cross-Section Sketch
O Teat hole locations O Dreinfield orientation and layout Referenced depth from original grade:
O Property lines O Trench/bed dimensions and critical O Septic tank lid and draintield cover
O Ecbl8tg end proposed wells within distances within layout depth
100 Rofptnperty lines O D-BoxP rrV locations
O Critical distance measurements to cuts, O geptic tank/pump chamber location Reference depth from original grade
banks,and surface water O Observation port location and restrictive strata:
O Location and orientation of curtain O Clean-out location O Laterals,trench/bed top and bottom
drain and all absorption components O Manifold placement O Curtain drain collector
O iocation and dimension of primary O Orifice placement O Sand augmentation
system and reserve area O Lateral placement,with distances to
O Buildings edge of bed Other cross-section detath
O Direction of slope indicator O AudibleMsual alarm referenced O Observation ports and clean."
(3 Wateribtes O Scale of drawing shown on scale bar
,I
O RoaWessements/driveways/
!fig ,
O Critical resource lands(if applicable) 1
O North arrow and•scale of drawing
shown on scale bar
Additional Information
O Design staked out
O Operation and Maintenance Notice
Attached
Waivers)Attached
R
The undersigned designer does, C3 does not,waive a req7L)
ent to be notified by the installer of the installation and given 49
bons to perform a final Inspection prior to cover.
Si ture of Designer ate
The undersigned has reviewed this design on behalf of Mason County Depa�ment of Health Services and determined it to be in
compliance with state and local on-site regulations: ^\(//�J
Environmental#WthSpecialist Date
DENCR APPROVAL isVAUDOtaYWDERTHEFOLLOWDtCCOMMON'
✓ The design is stamped`Approved'by Mason County Department of Health Services.
✓ The On-sW Sewage Permit has not exphed,the Permit Fxttlratlon Date Is::1 _
✓ The system is installed by a certified installer.unleis prior authorization is obtained from mum county
Dapattmmt of Heath Sec ACM
✓ Dalmtield the conditions have not been altered to adversely affect eonditlow of design
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Performance Data
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Pump Characteristics.'
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Hertz 60
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' . lemporshn 120°F Ambient >'
pesita A Total Hood (feet) 4 6 8 10 12 14 16 18 20 22 24
.Malalkn awA 1/4 HP 144 41 36 33 29 26 23 18 12 6 0
>{ Dy�Si:• 1-1/2'NPT 5PM 1/3 HP 47 45 43 40 . 37 34 30 26 22 16 10 +
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<, =HYDROMATICO 1840 Baney Road
Ashland, Ohio 44805Tel: (419) 289 3042