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HomeMy WebLinkAboutSWG Application / Design / As-Built - 4/16/1991 2 � �� f rYrll " � , •} 91 MASON COUNTY DEPARTMENT OF GENERAL SERVICES ENVIRONMENTAL HEALTH 426 W.CEDAR/P.O.BOX 186/SHELTON,WA 98584 PHONE(206)427.9670 NT E f C L All"55 PHONE r It P SF�4 PROPERTY OWNER A ADDRESS PHONE CITY ZIP SEWAGEC+'I//�� �� ' CONTRACTOR S0AIc.e�L D, 6G IN DESIGNER .a I LEGAL DESCRIPTION L S- l(P C-C C. I T Gam"" 3JLX34-13- iooso a 04 S? 7 .�U/Cvee , TYPE Of NO. OF X LOT BUILDING�P�1 -BEDROOMS E _ SIZ 3 SINGLE RESIDENCE PUBLIC WATER WATER SYSTEM '"' SYSTEM NAME COMMERCIAL ONLY LIQUID WASTE G.P.D. DIRECTIONS TO SITE: Q 1 . KA r 0,N T , SITE PLAN AND SPECIAL STIPULATIONS (INDICATE DIRECTION OF DRAINAGE) ATTENTION 6l1ILDIND DEFT. Due to npuiroa high elevation of optic tank,sewage outlet on 10I Mdation must be kept high,so L SklOplvlMdtlO@Nfalk.sLO,trt WHITE-OFFICE COPY:YELLOW-INSTALLERS COPY;PINK-PROPERTY OWNER'S COPY;GREEN-BUILDING DEPT.COPY SEWaG� SYSTEM PERMIT APT-LIEAtION . l t T 1 MASON COUNTY DEPARTMENT OF GENERAL SERVICES FOR DEPARTMENT USE ONLY ENVIRONMENTAL HEALTH BATE rtAsFOR JLEE, ' ' 'A 426 W.CEDAR/P.O. BOX 186/SHELTON,WA 98584 PHONE(206)427-9670 I APPLICANT # FDESIG�'ATE'M' ' ' 0rQv O Ap1§A PHONE : REQUIRETyh PRo RTYO TA • ATION-, ❑Approved; tlhloSdt{ ®vetk ADDRESS -_-- PHONE BY:_ CITY ZIP DEPTH TOWATER'TABLE ' SEWAGE SEWAGE F S0 TYPE; ' CONTRACTOR N S�IF � _ �' b.� /l./DESIGNER LEGAL DESCRIPTION �t' n-- / / i jaE 3Ll-1 9 �0: � � sae a9v&TMR�s ra mar TYPE OF NO. OF LOT " a s #m,•p a a a e BUILDING y�" I'� 1 -BEDROOMS SIZE a=N X ��� s ^ a e w m= SINGLE RESIDENCE �(I PUBLIC WATER _ n WATER SYSTEM '"' SYSTEM NAME— SEP.TI C'TANK-(S) GAL. LIMP IR i # COMMERCIAL ONLYf ,aFem%i LIQUID WASTE G.P.D. DIISTRIBtITION TILE TOTAL r. r f'_*f eir, DIRECTIONS TO SITE: m P A * m m i PILTRQ7(DNAREATOTAL TASfTlhkt,, . ., ybY q}�mwPFN I); FINAL IN ION ] EWRIE $ KKK V STRAW ast ,�q, S+ rr '�q 'I it t t : if ,eYEk�l4fe maw �+ {{,,#�cm SITE PLAN AND SPECIAL STIPULATIONS x = } " "IY= # * mN�Eear 00A w mph m awM ��' (INDICATE DIRECTION OF DRAINAGE) CROSS SECTION of TRENCH' ATTENTION BUILDING DEPT. DUO to required high elevation of UptIC tank, sewage owlet en foundation must be kep:high, so L �a la►Otwsbdl�Natank.sl.G.t,ri,q. WHITE-OFFICE COPY:YELLOW-INSTALLERS COPY;PINK-PROPERTY OWNER'S COPY;GREEN-BUILDING DEPT.COPY DESIGN FORM - PAGE ONE Pe isad 12/28/93 Lwill be reviewed when 3 copies of each of the following items are submitted: 1►L72 m�7 leted design form that has been signed and dated V IR leted Resource Lands and Critical Areas Checklist attached • ed plot plan, including all applicable items on checklist !AUG 22 �y1L• Scaled layout sketch, including all applicable items on checklist i • Cross-section sketch, including all applicable items on checklist f PARCEL IDENTIFICATION Permit Number C / /'y ExTay�s� Designer's Name /N� S Applicant's Name (sera � (C/4u�C_f G Prop. Owner's Name BOUCWt �,QLT A-S KCrL Mailing Address (4 A/,. Mailing Address S, S6/ /?/1, /L/CELSL—W / �--��Y 9Cs Zlp G1Cy 3<sC� 21p Assessor's Parcel No. 3.�- 3110 /Oo" Subdivision (iv�1v�-Digit Numbs) (N�mY/OSvl�ion/01 ech/Lot) Mason Count D t ' DESIGN PARAMETERS E J J ✓ Date ✓ Designed Vertical Separation / E Mound Subsurface Pressure Gravity Bed Trench •n II � � 1 .Septic Tank/Drainfield Specifications t No. Bedrooms Pressure Distribution? ED Yes No Dail Flow '-...... . . ...•'--••'• .......... ......... : :::::: Y d ••••••--- - - - : (If yes, proceed. . . ) Septic Tank Capacity /,eV gal Receiving Soil Type (1-6) L -,3 Receiving Soil Appl. Rate'?/ /ft= Laterals Trench/Bed Bottom Area O ft, Schedule/Class Trench/Bed Width /Q ft Length ft Di eter in i Elevation Measurements mber Orig. Drainfield Area Slope eparation . ft Final Drainfield Area Slope _ -('� % Orifices j Depth of Bottom of Trench/Bed (, Total Number of Orifices d from Original Grade in ameter in i Spacing O in Manifold Schedule/Class Length ft Pump Required? Yes No Diameter in �, ....•• .......•....••. (If Yes, proceed. . ................... c EFEcEcEc ifEEEcEcicEcEc Transport Pipe !, Schedule/Class Pump/Siphon Specifications Length ft Difference in Elevation Between Pump Shutoff Diameter in and Uppermost Orifice ft Dosing and Pump Chamber 8 Doses/Day Uppermost Orifice is 11 higher, lower Dose Quantity gal than Pump Shutoff Chamber Capacity gal Capacity @ Tot. Pres. Head qpm " Calculated Tot. Pres. Head ft (Attach Pump Curve) + nr• s , g DESIGN FORM - PAGE TWO Revised 12/26/93 DESZGR CHECKLISTS � Scaled Plot Plan Scaled Layout Sketch 7drainfield n Sketch ��� pth from orig- '-' Test hole locations �Drainfield orientation and layout Property lines (�� ank lid and (�� `- Trench/bed dimensions and cover depth Existing and proposed critical distances within wells within 100 ft layout Reference depth from orig- E Of property lines inal grade and restrictive t Critical distance D-Box/"T"/"L" locations strata: 1 / �� # measurements to cuts, Septic tank/pump chamber Laterals, trench/bed - banks, surface water location top and bottom 19/ (�- III `-' Location and orientation '--� Observation port location El Curtain drain collector of curtain drain and all ❑ C absorption area Cleanout location Sand augmentation components Manifold placement No external reference needed: Location and dimension (�-, t of primary system and El Orifice placement '� Observation ports and i reserve area cleanouts 11R©i Lateral placement, with Buildings distances to edge of bed Additional mound information: El-- Direction of slope Audible/visual alarm ❑ Upslope and downslope I indicator referenced fill width Waterlines Z'�� —' Scale of drawing shown 1:1 Settled cap depth at j on scale bar center and edge of bed Roads/easements/ i driveways/parking Additional Mound Information: Sidewall slope Critical resource lands Endslope width Up/downslope bed elevat. (if applicable) ❑ Overall fill dimensions Completed Resource Lands and North arrow and scale of Critical Areas checklist drawing shown on bar i i i! 3 DESIGN APPROVAL i finstallerned designer does, �oes not, waive the reqirement to be notified by the the installat' and give 48 urs to perform a final inspection prior to a son s ned has rev' we an ove this design on behalfo Mason County of Health DESIGN IS O ID IF STAMPED "APPROVED" By MASON CO. DEPT. OF HEALTH 1\ T? C I i ' W f I _ a � i a � i I ! f( 1 j T i fl i i f G O ' j i f X Mason County Ce,t.`i-�ea:fh ;'ed;x; , N APPROVED Initials r. �.` Date O'UZ SZN }1 Gt ovL . . I I i h p to I , i � E I I I S I f 1 III } M - aso n Co u oty G � i — r { ���e�t. ieaiih Serv.ces 1 L ® V e r C i Initia/SV date Cl- - - - 1 N Z T 3 , I I A � i W Y r ^ � VV •1 T TD n i 199 � _ o I f^ Gay C Jy � N � ti i �} 7• 'td��Por i b o Coo oq a MCA©: Q o , g ON—SITE SEWAGE INSTALLATION FINAL INSPECTION DATE CALLED IN: 1t✓' rI TIME: INSTALLER: pevA APPLICANVOWNER: CALLER: / ✓i. PHONE # OF CALLER: SWG #: 9 q PARCEL NUMBER: "2 1390O&Q SUBDIVISION: DIVISION: LOT: ...................................... . .. ................................... .... ..d`.... ............. SYSTEM TYPE (CHECK ONE) : 111 PRESSURE GRAV Ty INSPECTION SCHEDULE (CHECK ONE) : - APPOINTMENT PLUG IN :::-: ......::::::::::::::::::.::::::::::::......::::::::::::::::::::::::::::::::::::::::::::::::::::::: :::::::::::::::: ......................... . ........:.:.................................................. STAFF INITIALS: w h:callin.w Revised 06/17/94 ON-SITE SEWAGE INSTALLATION STAFF INSPECTION REPORT STAFF �IST CONFIRMED BY INSPECrOF? I. SEPTIC TANK Yes No Comments A) >5 ft from foundation? V _ B) Bldg stubout to septic tank: cleanout if not 1-2%? V C) Baffles intact and clean? V D) Dividing wall intact? \I _ II. D-BC1 led ' w r or speed leveler (circle one)? y_ III_ ➢FAIEFIELD A) >10 ft from foundation and >5 ft from property lines? `1 B) Laterals level to it inch F end caps present if not looped? v C) System dimensions the acme as shown on the design? D) Gravel clean, properly sized, and proper depth? E) BAESSURE SYSTEM 1) Send quality ASTA C-33? _ 2) Bead height uniform and z24 inches? 3) Cleanouts and observation Porte present? 4) Mound: Side slope 3:1? 5) Owner informed electrical connections must be made by licensed electrician? _ LV. POTABLE NATM LINES A) >10ft from field or double sleeved? V 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? VI. AS BRILT NEQOIRED'i �1 VII. 013HR C009KNIS The undersigned has reviewed this installation and verifies these findings on behalf of Mason County of Health Services. hccallin. Revised 06117/' <t3-BUILT FORM - PAGE ONE R—i--d 07/12/9l PARCEL IDENTIFICATION ( Permit Number SWG9 �( - �e z 2 E Subdivision ^u Installer's Name v` A ( ��) 1J$ L S'56 C, Assessor's Parcel NO. Designer's Name a-P>tN{u/A INSTALIAR CHECKLIST I. SEPTIC TANK Yea No N/A A) >5 ft from foundation? s) Building stubout to septic tank: cleanout provided if not 1-2a _v C) Baffles intact and clean? ci _ D) Dividing wall intact? II. D-BOX A) Water leveled? V_ B) Speed levelers used? C/ 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 Doped? D) System dimensions the s own on the design? E) Gravel clean, properly sized, and proper depth? L/ F) PRESSURE SYSTEM 1) Sand quality ASTM C-33? _ 2) Head height uni rm_.a,a �Zinches? L 3) Cleanouts an bservat L�s present? t� _ 4) Mound: Side elope 3:1? IV. POTABLE WATER LINES A) >10ft from field or double sleeved? B) Wells >100ft from drainfield? 1� 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 Row "A," check box from Row "B," sign.and date the certification. A I certify that I installed the system 1:1I certify that all deviations from /31�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. B. (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 in all r ce ifi ion. The undersigned approves this inst lation of behalf of Mason County Department of Health Services. L^ r '1%P-DULLl rllicM - YAlih '1'WU ae"isoe 07/12/9 a PARCEL IDENTIFICATION Permit Number SWG9 — (oZ1 Z 4F�V77 A. Subdivision Installer's Name 7l//N S�IJ`;� C Assessor a Parcel No. 3q�/ 3 V/ 3 Designer's Nam ...... AS-BUILT DRAWING CJu1TI0ss K Mr adjustments to septic tank location and drainfield orientation made in the field by the luetallmr era gemarally ac- ceptable to both the department and the designer, but could in certain camma compromise the viability of the apstea. It is the in- stallar'a responsibility to obtain prior written approval [Mon either the health department or the dmigner before making any devi- ations from the design that atfect system viability. Any deviations from the approved design most be sham above. ASS--BUILT CHECKLIST Drainfield orientation -6beervation port location Q-Undisturbed native soil and layout between trenches F%4 ❑� Cleanout location Trench/bed dimensions and M-North arrow critical distances within El Manifold placement (�_� layout Scale of drawing shown El orifice �r-�,i/� Orifice placement on scale bar '� D-Box/"T"/"L" location `-+''- -Lateral placement, with Additional Mound Information O-peptic tank/pump chamber distances to edge of bed ❑ locationEf_ Endslope width ��}} �� Location of wells, roads cation of buildings 0 Overall fill dimensions