HomeMy WebLinkAboutSWG93-1682 - SWG Application / Design / As-Built - 12/28/1993 PERMIT NO. SWG "— I m a
MASON COUNTY DEPARTMENT OF HEALTH SERVICES a W
n iD
426 W. CEDAR/ P.O. BOX 1666/SHELTON, WA 98584 Date e� g y. o
PHONE (206) 427-9670 Receipt o.
Amount$ Z f
m
c Qct a mej tc"p I Z - _ j CHECK APPLICABLE ITEMS ✓ m m
MAILING ADDRESS: DAYTIME PHONE: INSTALLING NEW SYSTEM 4
Z S S . t REPAIRING OLD SYSTEM o'
GE-573 t
STATE:CITY: ZIP: EXPANDING SYSTEM y
99,g11 SINGLE FAMILY m
PROPERTY ADDRESS: OTHER , Z
C L100 SPECIFY: 3
SPECIFIC DIRECTIONS FOR LOCATING SITE: � ll PRIVATE WELL 1 m
6r'o( 6AL2 -fur ri kt s ota c�u„« PUBLIC SYSTEM
SYSTEM ID NUMBER
o-% 4%n rear c; SYSTEM NAME I�
APPLICANT
NAME Glur i�I.o wct0 �`
Name of Lot ft. 9!j MAILINGADDRESS e1z.,S S ter W
Installer S tivn LJa RSS 3
t Size: /•0 acres TELEPHONE qZ7- ei/5 e Z
Name of um er o SIG TURE c
I�
Designer Bedrooms 3 XNITs
PLOT PLAN U 3-9,3j IL4
Draw a dimension II I t plan, '��!
including: I Y Y I � -� Q
SAY
❑Precise locatio a/O1
st a� ;� GI ra.urkr
holes,showing { Z I Irk *
measured distaP to oo v
property bounda cv , 0
❑Entry road;othaQds,►i ® .°r. ..�
driveways. I"
NOTE: DO NO IN
SYST�N
��rt 1Zon0 � r�N
J
OFFICIAL USE ONLY. DO NOT WRITE BELOW DOUBLE LINE.
T 1-H w 2 SOIL LOGS Tick
-SAW 0-01 - SAw 0-11i "~I %AW
-gocti tbAs ILA (1H"- cowS-W H-`(d - cow SAW
14-!t5 - covi S . S 4vtd ! �r4vv1
36- S�4tnrkl�� v✓AV Depth from Original
Grade to Restrictive a
Layer or Water Table: 3c —In.
DESIGNER DESIGNATION SCORES MINIMUM SYSTEM REQUIREMENTS
F nding Soore Designer Level: ❑One l Iwo
Soil Type -3 o,Ar o
Vertical Separation (�. � Septic Tank Daily / �
_ Capacity: W Gal. Flow: .3IG�J GPD
Slope C� - O S
Appl. Infilt.
Parcel Size t Ac• t Rate GPD/FT2 Area �Q FTZ
Distance to Shoreline ft. — Total �7s Inspector Date
COMMENTS/CONDITIONS FOR APPROVAL
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Any change from the r if a duasneifftthe one�nlel Of ilil9 alteration affecting the system desi n may invalidate this permit.
This Perm explrea Owns trollnn tltlaa pe�tf permit may be appealed to the Health&gr withln 10 days of denial date.
SITE:1 Required ❑NotAppro✓ed DESIGN: p(Approved O Not Approved INSTALLATION.�ppproved El Not Approved
BY: !rt DATE:I At_q,y BY: ��� DATE:.2 q-qy BY: A ALr DATE:
TOP: Health Dept. Copy MIDDLE: Designer's Copy BOTTOM:Applicant's Copy
MASON .COUNTY DEPARTMENT OF HEALTH SERVICES
POST OFFICE BOX 186
SHELTON, WA 98584
(206) 427-9670
FAX 427-8425
M DATE:
E ..
M 11 •
® To:
R
A
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M ® RE: Design for Cje (tA LA4r Parcel No. 3� �12.3Z `1001�
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Your design for the above referenced parcel has been reviewed and
hereby approved. AAl1
N�
Your design for the above referenced parcel has been reviewed and is
hereby conditionally a=roved. The conditions) for approval are:
a1GAPALrddSSSQc�io cJr 3��iC �gnk � ,(C.4�c c52 5 �arf! (SvPr )wn�f q�d
a • � a I U i�.nfr� lad uwu., ,
Your design for the above referenced parcel has been reviewed and
cannot be ayoroved. The reason(s) for not approving the design g are:
a
a
a
NOT My variation Cron auto sltanaclva system guidelines must be clearly Identl(lad 1_1 t1e
design and jus ti CS ad with technical dnu. The ndequary aC tachnical ]us tl Cie.tlon w111 be aa.esaed
by the health depar:xnc within me context oC current -Maptsd design pra�lces, depnr-.�encal
policy, and Level One and 'No Design standerda.
DESIGN FORM — PAGE ONE s ism I2?29/93
- A design will be reviewed when 3copies of each of the following items are submitted:
• completed design form that has been signed and dated
• Completed Resource Lands and Critical Areas Checklist .attached
• Scaled plot plan, including all applicable items on checklist
• Scaled layout sketch, including all applicable items on checklist
• Cross-section sketch, including all applicable items on checklist
PARCEL IDENTIFICATION �7 ,/
Permit Number `3z, Designer's Name o 3YhP
Applicant's Name GAea YWCA JoQU. ZD"P Prop. Owner's Name
Mailing Address Mailing Address
P
C S.Cy 9CSCw 21p ity a-t..'OCR Zip
3213Z329DbLfl Subdivision lie' E pp! '(I 1,/ r•
Assessor's Parcel No. i re
(ivolva-pigi� Number) (Ljpq`�Y�k" `�^
Mason Grjut
DESIGN PARAMETERS AP
Date
Designed Vertical
Separation
(
Mound Subsurface Pressure Gravity Bed Trench jz. in
Septic Tank/Drainfield Specifications
No. Bedrooms 3 Pressure Distribution? Yes No
........................ ::........... ::::::::::
Daily Flow 3Lob d (If es, proceed. . .
........................
y ::::::::::::::::::::::::
Septic Tank Capacity LeI2D /ZQ0 gal
Receiving Soil Type (1-6) 3
Receiving Soil Appl. Rate d/ft' Laterals ZOQ
Trench/Bed Bottom Area 4,S0 ft2 Schedule/Class
Trench/Bed Width 3 ft Length -G o ft
Diameter �{ in
Elevation Measurements ,,r Number 3
Orig. Drainfield Area Slope AALS )Vgk Separation ft
Final Drainfield Area Slope " $ Orifices 7�
Depth of Bottom of Trench/Bed Total Number of Orifices
from Original Grade Z in Diameter in
�p'�ope Spacing 2
2 in Manifold
Schedule/Class �D
Length 2D ft
Pump Required? 9—Yes El No Diameter 2 in
................. .... .................... .
(If yes, proceed. . . ) Transport Pipe
................ ..... 2DO
....... ........:.....
Schedule/Class
Pump/Siphon Specifications Length 20 ft
Difference 'in Elevation Between Pump Shyrtoff Diameter M. in
and Uppermost Orifice 7 2-S ft Dosing and Pump Chamber
� Doses/Day 2
Uppermost Orifice is ED'�hlgher, lower Dose Quantity 100 gal
than Pump Shutoff Chamber Capacity --3 00 gal
capacity @ Tot. Pres. Head CA�� gpm
Calculated Tot. Pres. Head /Z.0 7. ft
(Attach Pump Curve)
•IhESIGN FORM - PAGE TWO n ,i.-d 12/28/93
D&SIGN CHECKLISTS f.
�j
Scaled Plot Plan Scaled Layout Sketch Cross-Section Sketch
aI� Reference depth from orig-
Test hole locations LJ Drainfield orientation inal grade:
and layout
Property lines Septic tank lid and
❑
Trench/bed dimensions and drainfield cover depth
Existing and proposed critical distances within ,
wells within 100 ft layout Reference depth from orig-
of property lines inal grade and restrictive
❑ 0 D-Box/"T"/"L" locations strata:
� Critical distance
measurements to cuts, E/ Septic tank/pump chamber Laterals, trench/bed
banks, surface water location top and bottom
Location and orientation Observation port location Curtain drain collector
of curtain drain and all ❑
absorption area Cleanout location Sand augmentation
components
Manifold placement No external reference needed:
Location and dimension (�'
of primary system and u Orifice placement Observation ports and
reserve area ❑ cleanouts
Lateral placement, with
Buildings distances to edge of bed Additional mound information:
Direction of slope 2 Audible/visual alarm El Upslope and downslope
indicator referenced fill width
Waterlines Scale of drawing shown 0 Settled cap depth at
on scale bar center and edge of bed
Roads/easements/
driveways/parking Additional Mound Information: Sidewall slope
Critical resource lands El Endslope width EJ Up/downslope bed elevat.
(if applicable) ❑
Imo" Overall fill dimensions _Completed Resource Lands and
LJ North arrow and scale of Critical Areaa.;Cheaklist
drawing shown on bar
DESIGN APPROVAL r-�>
The undersigned designer does, does not, waive the reqirement to be notified by the
installer of the installation and given 48 hours to perform a final inspection prior to
cover. /
The undersigned has reviewed and approved this design on behalf of Mason County of Health
Services.
CAUTION: THIS DESIGN IS ONLY VALID IF STAMPED "APPROVED" BY MASON CO. DEPT. OF HEALTH
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FINAL INSPECTION - SEPTIC SYSTEM
DATE CALLED IN•
TIME-
INSTALLER:
APPLICANT/OWNER: I
CALLER:
PHONE # OF CALLER: o b
C �f
SWG#:n
PARCEL NUMBER:
SUBDIVISON
Division Lot
PRESSUR or RAVITY
(Ci cl one)
- �/'� APPOINTME2Q r P IN
Staff Initials l V )
FINAL INSPECTION
SEPTIC SYSTEM CHECK LIST
I) SYSTEM TYPE YES NO COMMENTS
•
A) CONVENTIONAL: (TRENCH D)
B) ALTERNATIVE: (MOUND/ UBSURFA yC
II) SEPTIC TANK
A) > Five Ft. from Foundation
B) Foundation-Tank Line Slope:
Cleanout provided if not 1-2% {pf
C) Baffles Intact / Clean
Dj Dividing Wall Sealed
III) D-BOX
A) Water Leveled , ^
B) Speed Levelers Used
IV) FIELD
A) > Ten Ft. from Foundation
B) > Five Ft. from Property Lines X _
C) Laterals Level to ± 1 inches _
D) End Caps Present If Not Looped
E) Square Footage Adequate
F) Gravel Depth Adequate
G) Gravel Clean
H) PRESSURE SYSTEM
1) Sand Quality ASTM C-33 _
2) MOUND: Sand Slope 3 to 1
3) .Head Height > 24 inches 1 iazl ov -
4) Cleanouts Present
5) Observation Ports Present.
V) POTABLE WATER LINES
A) > Ten Feet From Field
Components or Sleeved _
B) WELL > 100 Ft. from Field
VI) PUMP TANK
A) Screen Installed
1) Basket / Effluent Filter
B) Riser For Access Present
C) Alarm Installed v
VII) AS BUILT REQUIRED --h
COMMENTS
Signature f Sanitarian Date
vised: 10/20/92
AS—B(J%LT FORM — PAGE ONE RWis.a 07/12/93
PARCEL. IDENTIFICATION
Permit Number SWG9A -I&8 Z Subdivision
d�7 (ea.,..�iasvi.sen/sieek/zoc�
Installer's Name /�joL — f Cl ay (f' 014�Q'Oy Assessor Is Parcel No. 72 /3Z -7ZSOo /
Designer's Name A' k ", ro— A'rraG
INSTALLER CHECKLIST
I. SEPTIC TANK Yes.. No N/A
A) >5 ft from foundation? Ly _
B) Building stubout to septic tank: cleanout provided if not 1-28 _
C) Baffles intact and clean?
D) Dividing wall intact?
II. D-SOX
A) Water leveled? )K-
B) Speed levelers used?
III. DRAINFIELD
A) >10 ft from foundation and >5 ft from property lines? _
B) Laterals level to tl inch? �[ _
C) End caps present if not looped? _
D) System dimensions the same as shown on the design? _
E) Gravel clean, properly sized, and proper depth?
F) PRESSURE SYSTEM ,
1) Sand quality ASTM C-33?
2) Head height uniform and 2t24 inches? _
3) Cleanouts and observation ports present? _
4) Mound: Side slope 3:1?
IV. POTABLE WATER LINES
A) >10£t from field or double sleeved?
B) Wells >100ft from drainfield? -
V. PUMP TANK
A) Screen basket or effluent filter (circle one) installed?
B) Riser installed for access? _
C) Alarm installed?
CERTIFICATION OF INSTALLATION
Installer: Check box from Raw "A," check box from Row "B," sign and date the certification.
(
A. 4�j I certify that I installed the system I certify that all deviations from
without any deviation from the design the design stamped "APPROVED" by MCDHS are
stamped "APPROVED" by MCDHS. shown on the reverse side of this form.
i
B. 9 I certify that I contacted the I did not contact the designer prior
designer and left the system open for to final cover because the designer
inspection up to 48 hrs prior to cover. waived the notification requirement.
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 inst er certification.
> Z- s
The undersigned approves this install ion of behalf of Mason County Department of Health
Services. n -
'ra�
q.alth Ia.D.otor - p.r. ,
•BUILT FORM - PAGE TWO Revised 07/12/93
`.
PARCEL IDENTIFICATION
Permit Number SWG9 - Subdivision
(Name/m ivl®ion/Bloolcr/,Lot)
Installer's Name ��U- --S*+n �l/Iq�(Al Assessor's Parcel No.
Designer's Name f0G czweivr—nixie N.,...daz,
AS-BIIILT DRAWING
eo
Y�
_ION: Minor adjustments to septic tank location and drainfield orientation made in the field by the installer are generally ac-
'.able to both the department and the designer, but could in certain cases compromise the viability of the system. It is the in-
-ler's responsibility to obtain prior written approval from either the health department or the designer before making any devi-
:ns from the design that affect System viability. Any deviations from the approved design must be shown above.
AS-BIIILT CHECKLIST
Drainfield orientation Observation port location El Undisturbed native soil
and layout ❑ between trenches
-1 Cleanout location ❑
J Trench/bed dimensions and North arrow
critical distances within Manifold placement ❑
layout ❑ Scale of drawing shown
D-Box/"T"/"L" location
Orifice placement on scale bar
❑
Lateral placement, with Additional Mound Information
Septic tank/pump chamber distances to edge of bed El location El Location
width
Location of wells, roads
Location of buildings Overall fill dimensions