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HomeMy WebLinkAboutSWG2005-00340 - SWG Application / Design / As-Built - 6/1/2005 MASON COUNTY DEPARTMENT OF HEALTH SERVICES Official use only D 426 W. CEDAR ♦ PO BOX 1666 ♦ SHELTON, WA 98584 PERMIT NUMBER (360)427-9670, Ext. 352 SWG����� APPLICANT DATE ISSUE DATE `OJ' 0 PRoPEI�"I> 5 of oC � 'x 0S UJ MAILING ADDRESS DAYTIME PHONE RECEIPT NUMBER / L7 — '✓75Y 0 02 I -23"L AVE5 � CITY STATE ZIP 0 L-//-IPIA WA q 8S() NEW SYSTEM PROPERTY ADDRESS REPAIR SYSTEM C TABLE 6 REPAIR (`1� NATURE SINGLE FAMILY w_ OTHER Please describe Z NAME OF DESIGNER PHONE NUMBER J I M l+aiv 2y '3 too NUMBER OF BEDROOMS PRIVATE WELL v 3F PUBLIC WATER SYSTEM LOT SIZE: ACRES FT x FT SYSTEM WFI# S 3-� I X (pSS SYSTEM NAME SPECIFIC DIRECTIONS FOR LOCATING SITE /A/,vw -r o� &w)l 3 r—"rl S I+F-[-To V�'N K� t�PT 0 Al 1�4 UE N DER l /V-fo &Ibcwr oN WILLOWL 6L.1G Al bcw.V I+lli- 5 , frs ISA-T gDTroM C WlfE�19- /US TVAn/ S L-F-P-T; 3 Official use only below this line Cr DEPARTMENTAL SOILS LOGS/COMMENTS/CONDITIONS CD LS 0 c c Lo fi SOIL TEXTURE CODES I� V =very G=gravelly S=sand L-Loam Si=silt C=clay E=extremely This application is for design approval only. IJ An installation permit will be required to install the system. • All systems require ongoing Operation and Maintenance as specified in Mason County Onsite Standards. I uk • All onsite sewage systems must be designed by Licensed Onsite Wastewater Designer or Professional Engineer,unless prior approval is granted. • All onsite sewage systems must be installed by a Mason County Certi(ed Installer,unless prior approval is granted. • Onsite sewage system design approval does not imply other building site approvals. • Any change from the specked use of the property or any site alteration affecting the system design may invalidate this permit. I d • This permit expires 3 years from the date of site review.Denial of this permit may be appealed to the Health Officer within 10 days of denial date. I It SI ATURE DATE =RMVED BY 12�i ATE DESIGN EXPIRATION DATE r White Copy-Health Department Yellow Copy-Designer Pink Copy-Applicant MASON COUNTY DEPARTMENT OF HEALTH SERVICES September 27, 2005 PO BOX 1666 SHELTON, WA 98584 SHELTON (360) 427-9670 FAX (360) 427-7798 Jim Henry ELMA (360) 482-5269 PO Box 14531 BELFAIR (360) 275-4467 Tumwater WA 98511 SEATTLE (206) 464-6968 RE: Design for CAMPBELL PROPERTIES OF OLYMPIA Case No: SWG2005-00340 Parcel No: 321367500040 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 i Environmental Health Mason County Health Services COMMENTS: 9/27/2005 1 of 1 SWG2005-00340 MASON COUNTY DEPARTMENT OF HEALTH SERVICES June 09, 2005 PO BOX 1666 SHELTON, WA 98584 SHELTON (360)427-9670 FAX (360)427-7798 Jim Henry ELMA (360)482-5269 PO Box 14531 BELFAIR (360) 275-4467 Tumwater WA 98511 SEATTLE (206)464-6968 RE: Design for CAMPBELL PROPERTIES OF OLYMPIA Case No: SWG2005-00340 Parcel No: 321367500040 Your design for the above referenced parcel has been reviewed and is NOT APPROVED. It does not meet the requirements or needs additional information. Please see the comments section of this letter for more 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: Please contact planning due to slopes being greater than 15%. 6/9/2005 1 of 1 SWG2005-00340 C/ e MASON COUNTY DEPARTMENT OF HEALTH SERVICES Environmental Health Personal Health PO BOX 1666 SHELTON,WA 98584 LOCAL(360)427-9670 FAX(360)427-7798 Application for Waiver/Appeal Amount Paid: Receipt Number: Instructions nd1 , 1.t,1l m �`l o_ t 1M I. Complete Parts I and 2. No determination can be made until untCil these parts are fully completed. 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 ( 0 y4 p 6d P✓aPe��t r S Date y- Mailing Address ZJJ -7 3?KO que N t Telephone .3b 0- '/6 3 -007`>' O L! ,vA je i s WA 185010 Assessor's Parcel Number 3 z 1 31, - -7 5 - 60010 Subdivision Name and Lot T;0 q 5�rucu UOL z P6 PART 2: Nature of Waiver/Appeal On-Site Sewage Requirements ❑ Food Sanitation Requirements ❑ Buildingpermitreviewpolicies ❑ Solid Waste Requirements X Location, WAC 246-272-09501 ❑ Group B Water System Requirements ❑ Holding tank WAC 246-272-12501 ❑ Water Adequacy Requirements ❑ On-Site Standards ❑ Enforcement Timelines ❑ Contractor certification requirements ❑ Departmental Determinations (Installer, Pumper, O&Af Specialist) ❑ Other Description of Waiver/Appeal(include justification,additional material may be attached): PJ lfoQr7wtJTflL sepr.0 Hooll or 3 z Applicant Signature� Date: Page 1 of 2 Updated:08-26-2005 PART 3: Health Department Evaluation (Staff Use Only) IA. Type of Determination Required: 1 B. Type of On-Site Waiver(if applicable): ❑ Appeal g,Waiver ❑ None required 19 Class A ❑ Class B ❑ Class C 2. Identification of Specific Code/Standard/Determination(includ@ date of determination or latest code/standard revision): Z 9(9 — Z 7 Z 09 So I t J 3. Nature of Appeal: /t t ,u,.;� t �{�4 cL 4,Lt < -t' G 4. Hearing Official: rb ❑ Board of Health .JJ Health Officer ❑ Pollution Control Hearing Board ❑ Health Services Director ❑ Certified Contractor Review Board ❑ Environmental Health Manager 5 Mitigating Factors: n 0--, 0 � 3� o -111� u o w,-V� d [,-di � c 6. 1 have reviewed this waiver/variance request. It is complete, and mitigation required by state and local policy has been submitted. Staff: __�: I/ L_,& Date: u 12 y I06 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 herebygranted. This decision is based on the following findings and conditions: ✓WUTi�_r I" fi&tt o ❑ 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 Date:D& 3, 0 Page 2 of 2 Updated:08-26-2005 � tMo.vTc /l�cl%5 The weN av,�/ez �z Porcvl #� 32/3�o-7s -d�/� f C f' e pkIl �of��rf�cs pa ca �uP Per✓vrissia`u I=o1e Tl.+e ! (ve�e IC2f"5e l �„yy o..�n (J Q y o��G� S(�Cra��� F�f'o✓n Say To 32� Q51<i✓U4 �o ,P_co�.tce � Z DESIGN FORM—PAGE ONE RcVlodJwMwY'•t999 A design will be reviewed when 3 cooles of each of the f0llowk18 Items are submitted: Carntrlsted deatpn corm ttnt has neon slpned and dated sealed WvLd skMd4 krdudkq all applicable Rams on anecko t ft sided pWW=r,kaNMinp all ap=bsllo itarrs on cneckm . Crostaacfbn sketeh,kwNaWq aM eppNoabk Moms on daduut 9 Permit Number SWG U� - U3'/J pesigaa's Name: ) M H EA/�L�I Applicant's Name:A M P!S>L� �/4 o P c-VLT l65 Assessor's Parcel No.: of I'�l07��O© _ Mailing Address: l on 7K ! 5(rcwKd°vo-�D�i itt tQom�nb eLtl A, 4 —t ;4MPiA- io ubvisi - stre zip (NameJDrvaioslslodcrteQ : Treatment Device 0 Glendon Biofilter O Sand Filter 0 Mound O Sand Lined Drainfield O Aerobic Unit-Make/Modek — 0 Disinfection Unit - Make/Model: Drainfield Type O'Gravity 07rench frGDraravelles Chambers Septic Tank/Drainfield Specifications Laterals ScheduldClass Number of Bedrooms Lmgth ft Daily tea' ` iO" Od Diameter in Septic Tank Capacity /�-oo gal Number Receiving Soil Type(1-6) 3/`{ Separation It Receiving Soil Appl.Rate Requirod Square Footage Orifices Designed Square Footage 1,20V Total Number of Orifices Percent Reduction Taken % Diameter in TrenchtBed Width '� ft Spacing M Tmich/Bed Length a c<D ft Elevation Measurements Manifold Schedule/Class o 0 Original Ihainfield Area Slope 33 % Length O New Slope if Altered 33 % Diameter Depth of Excavation from o2 in Profaned Manifold Configuration Used? oles ❑No Original Grade t (Ups in ) _ransport Pipe (Downatope) �o uule/Claasss ��'�Q.� 020 Designed vertical Separation �/ 310 in Diam�PON 0 in Gravelless Chambers Required? LJ Yes ONO 1�3.,O�ptional �G frig and Pump Chamber ❑Yes air. N 0;;� M PAP Required? Dose Quantity eal Pump/Siphon Specifications Chamber 9P eal Difference in Elevation Between Pump Shutoff and Uppermost Pump Controts: Timer(or)Elapse Time Meta(circle M r'e4cirod) Orifice: ft If Ttma-. Pump On .Pump Off Uppermost Orifice is 0 Higher, 0 Lower than Pump Shutoff Check the following components if they drain between doses: Capacity @ Total Pressure Head: enr� ❑Laterals ❑Manifold ❑Transport Calculated Total Pressure Head (Attach Pump Curve) DESIGN FORM-PAGE TWO IterkcQApra 24,1996 Scaled Plot Plan Scaled Layout Sketch Cross-Section Sketch est hole locations �Dramfield orientation and layout Referenced depth from original grade: O-Tmnch/hed dimensions and critical 9�Septic tank lid and drainfield cover Property lines depth �Exierin and proposed wells within distances within layout IOo ft of property lines Orr-D-Bow r/"L"locations p Critical distance measurements to cuts, O� tic tank/pump chamber location Reference depth from and restrictive strata:original grade banks,and surface water Observation port location t�Laterals,ttencLAxd top and bottom O Location and orientation of curtain t3 Cleanout locationO Curtain drain collector drain and all absorption components (3'Manifold placement O Sand augmentation ,ar Location and dimension of primary O Orifice placement system and reserve area crIatel placement,with distances to edge of bed Other cross-section detail: Buildings el'Direction of slope indicator O Audiblelvisual alarm referenced Or Observation ports and clean-outs O'weterllna 0­`Scale of drawing shown on scale bar '- ..�ti'atia t.6• o B'Roads/easements/driveways/ `. s parking ufdY is as frnnuri+ < O Critical resource lands(if applicable) Qp>is' > 9' arrow and scale of drawing North shown on scale bar Additional Information Zy-I)esign staked out O Operation and Maintenance Notice Attached O waivel Attached �x.i..` .'<••`�i, �p::kY�.S h - 5�}. ': , ril1�•{\` 1D�aNd,4.R The undersigned designer does, does not waive the requirement to be notified by the installer of the installation and given 48 hours to perform a final inspection prior to cover. g�ignature of Desi r 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 regulations: � Z7 0f - Environm Healtlt Specialist Date .ation: DESIGN APPROVAL IS VALID ONLY UNDER THE FOLLOWING COMMON: : Of Health Services. J The design is stamped APp�ed"by Mason County Departm t7 ✓ The On-site Sewage permit has not expired,the permit Expiration Date ✓ The system is installed by a certified installer,unless prior authorization is obta1n d m Mason County Department of Health Services. J Drainfreld site conditions have not been altered to adversely affect conditions of design approval G ' j �JIM HENRY DESIGN SERVICES, INC. MASON COUNTY DEPARTMENT OF HEALTH SERVICES ON-SITE WASTEWATER DISPOSAL SYSTEM DATE: May 25, 2005 APPLICANT: CAMPBELL PROPERTIES OF OLYMPIA 211 73RD AVE NE OLYMPIA,WA 98506 3• LEGAL: LOT 4 OF SURVEY VOL 2 PG 49 pM HENRY s�*� LICENSED DfTIGPlER PARCEL#: 321367500040 EXPIWP 08!51'00 PROJECT#: DESCRIPTION: NEW CONSTRUCTION, GRAVITY SYSTEM WITH INFILTRATOR PANELS PROJECT DETAILS: NUMBER OF BEDROOMS 3 GALLONS PER DAY(GPD) FLOW 360 APPLICATION RATE 0.60 DRAINFIELD -Absorption Area Required 600 SQ.FT -Absorption Area Designed 600 SQ.FT -Trench/Bed Length 200 FAPPROV ED -Trench/Bed Width 3 %SIC HEALTH DEPT SEP 2 7 2005 DRAINFIELD CROSS SECTION - Bed Depth 24 INCHES CEW -Graveless Trench 12 INCHES -Vertical Separation 36 INCHES - Fill Depth 12 INCHES SEPTIC TANK -Size&Composition 1125 GAL CONCRETE - New/Existing New ) / k� \ ■ & A > U- w 0 \ tt < im ! ° ) m§ \ 2 = \ ] § § 9 JP LU § \ § / a ] � k � � # }ul . - If \ � § a ) " APPROVED - DEPT ¥c H A . . SP2 ? 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N y0y C .a C_ C CD RZl V N 7 W °_' _ `D 1 3 0 fD o n CD � v W = 0 N x mm -m-I O _ r Z m n m O A m Z � n N m - m 2 IN N 4 N m D O m ] N , O m m m LL"< N Or: \ d d n = m W D 0 0 0 0 m A I C- m c 09 ` D m # � O 0 m � m w A w Z r N p, 3 v m - 0 D m m °,mb a M 0 z"' -O U rz m 900 U/ o d O 0 3 �1iF r ^ n A ro 6� r) v m 0 G) O Z G 3 .AO C A G� m 3 v N m D z �• ONSITE SEWAGE'SYSTEM A 4STA"' TIOW PEIt} T , MASON COUNTY DEPARTMENT OF HEALTH SERVICES ' 426 W. CEDAR ♦ PO BOX 1666 ♦ SHELTON, WA 98584 D (360)427-9670, Ext. 352 N .'SYSTEM INSTALLATION Cn ❑TANK REPLACEMENT ONLY(Attach Supplemental Tank Replacement Form) CD Cn , 'CERTIFIED INSTALLER N ❑ HOMEOWNER Official use only ��{ A CE PLICANT NAME PERMIT NO SWG APPLICANT ADDRESS ISSUE DATE Z II oCd u ve u! G� RECEIPT NUMBER CIT / STATE ZIP tjA Q FINAL INSPECTION v IN ZL,LEER AME AN�XL4ESS NAME CALL-IN DATE «. �M LIN((�G ADDRESS_cG-- DAYTIME PHONE INSPECTION APPOINTMENT Z �p�q f �r (� 9SS DATE/TIME / CITY yJTATE ZIP kX1A)�.✓ � ASBUILT ON SITE? OYES ONO ISC_PROPERTYADDRESS � ��—(nko U1//dig/ CD I hereby agree to comply with all requirements of the Mason County Department of Health Services Onsite Regulations and Standards. Upon completion of the work, the Health I' Department and the Designer shall be notified. All work shall be left open and uncovered until inspected. A completed asbuilt from the installer or designer must be provided at the time of I 0 final inspection. The applicant has the right to appeal decisions of the Health Department. 1t0 This permit is valid for one year from the issue date or the 1 expiration date of the septic design, which ever occurs first. � I- �TUN FCERTIFIED INSTALLER OR HOMEOWNER INSTALLER DATE Iv d (Q Io ICh Official use only below this line 10 FINAL INSPECTION COMMENTS 1- INSTA TI PPROV D BY DATE Revision Date:6/2/2005 White Copy—Health Department YellowCopy—Installer PinkCopy—Applicant 6/2/2005 AS-BUILT FORM lid January 4,1999 lyffi�� WOW Applicant [�...._�Lva 1( P�� _ Assessor's Parcel# 3zi3CQ75600—qn Permit Number SWGZog5- bo346 (TWON"1gRNul or) Installer �o k� EXCctua'1'.e14 Subdivision T2, y ame1Wy{t 101oLtaL z ) �I g (Namelni ) Designer `S { 1� NIA Yes PNor to Completion I. SEPTICTANK A) >5 ft.From foundation?........... ............................... ❑ ,� ❑ B) >50 ft from wells and surface water? .................. ............. ❑ 0 ❑ C) Bldg stab-out to septic tank:clean-out if not 1-2%? . ... ........... ..... ❑ ❑ D) Baffies intact and clean? . ... ......... .......................... .. ❑ 8 ❑ E) Dividing wall intact?........ ... ................................... ❑ Ja ❑ F) Risers installed for access? . ........ ............... ................ ❑ 10 ❑ G) Tank Size: i Z.eao gal.;Manufacture k� e_s 11. D-Box A) Leveled with water? .. .... . .......... .................... ........ ❑ k7 ❑ B) Speed leveler used? ...... . ... .... . ........ ...................... ❑ 0 ❑ III. DRAINFIELD A) >10 ft from foundation and>5 ft from property lines? . .... .. ......... .. ❑ Gr ❑ B) >100 ft from wells and surface water? ..... .... ...................... ❑ 0 ❑ C) >10 ft from potable water lines? .. ................................. ❑ 0 ❑ D) Laterals level to±1 inch&end caps present if not looped? .............. ❑ 0 ❑ E) Gravelless chambers utilized? ................................... .. ❑ 0 ❑ F) System dimensions the same as shown on the design?................... [3 , __ .: 0 ❑ . :. G)..Gravel clean,properly sized,and proper depth? ....................... 0 ❑ ❑ H) PREssunE SvsTEMs 1)..Siaad quality ASTM C-337 .................................... ❑ ❑ 2) dead height uniform and 2:24 inches? Actual head height ..... 0 ❑ ❑ 3) Clean-outs and observation ports present? ..... ..... . ........ ..... ❑ 0 ❑ 4) Mound: Side Slope3:1? ..... . ......... ......... ............. j ❑ ❑ 5) Owner informed electrical connections must be made by owner or licensed electrician and inspected by L&I? .............. la ❑ ❑ IV. PUMPIPUMP CHAMBE A) Screen basket effluentcircle one)installed? ................... ❑ 0 ❑ B) Riser installed for a ............ .. ........................0 ❑ ❑ C) Alarm installed? ......... .. ......... ... ... ...... . ............... .0 ❑ ❑ D) Pump make Pump model E) Chamber size gal; gal/inch; Chamber Manufacture F) Pump chamber draw-down inches per minute; Height of pump off bottom of pump chamber inches G) pump controls:rimer(or)Elapsed Time Meter (circle If installed); If timer is used Pump On—Pump Off v.':�'�g: w. Ihainfield&manifold orientation &layout X Trench/bad dimensions and critical distances within layout ?! tank Sepal ic(pu p acement ® Location of buildings. 5 t` Observation port&clean- old location. 13 Location of wells& roads. Undisturbed native soil between trenches. Ninth arrow CAUTION:Minor adjustments to septic tardy location and dreinteid orientation made in the field by the iosWler ere p ec��k m both the t and the but could in certain homes compromise the viabatty of the system. It is the installer's responslWity too prrar wfiaen approvd tom ather the show d�ortlre designer 6eforo eeaking any deviations from the design that shown shove. affect the system viability. Any devianwts from the approved design must be :w..::.y:.' 'r:`.i�i. ...:. r •x�.... .s: _r`a. �gk. >s x: c. a::. Installer-Check a box from Row"A"and"B";sign and date the certification. - - .- •- -' . ._ __.. . A. 0 I certify that I installed the system without any ❑ I certify that all deviations from the design stamped deviation from the design stamped"APPROVED"by "APPROVED"by MCDHS are shown above. MCDHS B. O I certify that I contacted the designer and left the 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 information contained herein is not accurate,there will be just cause for immediate suspension of my hiaWer certification. 3�-1 Z-6(9 �Ignz0 er The undersigned approves this installation on behalf of Mason County Dyp ri�tu t oeaeaServices. l3/a�nn—arpG/r� 0 � i t 4 iL ar v M Q7L ��'SEtn.va* ✓Zesr.ue, i o as -i 1=Q o o yo ` oWo 0