HomeMy WebLinkAboutSWG99-0043 - SWG Application / Design / As-Built - 3/15/1999 AASON COUNTY DEPARTMENrOF HEALTH SERVICES PERMIT NO. SWG —
• TITE
Date _426 W. CEDAR/ P.O. BOX 1666/SHELTON, WA 98584 ReceiptNo.PHONE (360) 427-9670 Amount$ CHECK APPLICABLE,io NEW SYSTEMMAILIN ADDRE DAYTIME PHON : REPAIR SYSTEMMAINTENANCE REVIEWATE: 'ZI :(DA SINGLE FAMILYPROPERTY ADDRESS: SPECIFY:SPECIFIC DIRECTION FOR LOCATING SITE: PRIVATE WELLM c FWW � t,ef� /� co-( COMMUNITY WELUPUBLIC S
SYSTEM WFI q
SYSTEM NAME I N
d� p APPLICAN
NAME G� (—
Name of Lot ft.x ft. MAILING ADDRKS
Installer Size: c acres w
TELEPHONE <,
Name of / um er o SIGNAT o
Designer Bedrooms X '
PLOT PLAN
Jott_ Lbws 3— l2 -4�
Draw a dimensional plot plan, 2
including: o �^
❑Precise location of tes Z
holes,showing 'J
measured distances t �v' LA
property boundaries. t to
v C�
❑Entry road;other road , rQ Z S Imo,
driveways. ' 9
NOTE: DO NOT N \ (2R) 8
SYSTE I N V\3
OFFICIAL USE O N T WRITE B O DOUBLE
4
SOIL LOG ti
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DESIGNER DESIGNATION SCORES MINIMUM SYSTEM REQUIREMENTS
Findin Score Designer Level: ❑One ❑Two '
Soil Type
Depth ��. Septic Tank Daily
Soil De
P t� Capacity: [anoGal. Flow: 3 (0 O GPD
Slope 10% Appl, Infitt.
Parcel Size 4—AR. 1 Rate 1 , GPD/FT- Area FT'
Distance to Shoreline - ft. Total nspector Date I
r COMMENTS/CONDITIONS FOR APPROVAL
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•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 cases a preliminary on-site
meeting between health department staff and the homeowner is required.
•On-slte sewage system design approval does not imply other building site requirements(i.e.RLC,Water Adequacy)have been met.
•Arry change from the specified use ct the properly or arty site alteration affecting the system design may invalidate this permit.
•This mlt expires 2 ears from the date of site review.Genial of this permit may be ealetl to the Health Officer within 10 days of denial date.
SITE REVIEW: DESI N IEW:XApproved U Not Approved INST LLATION;d4proved ❑Not Ap row
BY: DATE: 3-( BY: DATE: B . DATE:(t )4
TOP: Health Dept.Copy MIDDLE: Designer's Copy BOTTOM:Ap licant's Copy
MASON COUNTY
DEPARTMENT of HEALTH SERVICES
Shelton,Woshington 98584
(206)427-9670• Belfair:275-4467
ENVIRONMENTAL HEALTH PERSONAL HEALTH WATER QUALITY
P.O. BOX 1666 303 N. FOURTH P.O. BOX 1666 ;
i
MEMORANDUM
1
DATE:
TO: &b Lys),
FROM: 1 A,VV" lkv) O ,
RE: Design for AAA00,,. 4\\ Parcel # 134- it-1)00 3
'K Your design for the above referenced parcel has been reviewed
and is APPROVED.
(AC QOb Lys o1 .w � At-k- MC) webs w1.1*\y 100 �RA+
OE {1 r A d;AA, \c1 A-t-n
aYour design for the above referenced lot is NOT APPROVED. It does not meet
the requirements or needs additional information.
�?h+Ct'fl Pll
DESIGN FORM - PAGE ONE Revised Febmary 18, 1999
A design will be reviewed when 9 copies of each of the following items are submitted:
Sadpanud that laial�scpk oss�s �lin iplcaem checklist
l6d pot lninclin all ippplcabe on h checklist � Cr -seouon ketch,Including all applicable k on
checklist
Permit Number. cwc: Q � Designer's Name: t6r0
Designer's Phone#: 9 b^®�2
Applicant's Name: r N( d 1 w C Assessor's Parcel No.: 7J 2[(-- �1— 2��9
Mailing Address: 626021 , O^:4 s' (TwelveolgitNumber)
C,t2njn.G L!)A- Subdivision:
City State Zip ivisiotdalock/Lot)
09 NMI ,
Treatment Device �MR2 5 M9 LLJJ
Q Glendon Biofilter — Q Sand Filter Q Mound p ;9f T Lined Drainfield
Q Aerobic Unit-Make/Model: Q Disinfect on Unit - Make h%W<n�i LTA �ar
Drainfield Type A.PPRrED
p�s� Qged �Drainrock Initials -+
Q Gravity P'Trench Q Gravelles Chambers A
Septic Tank/Drainfield Specifications Laterals
Schedule/Class
Number of Bedrooms •;? - Length
Daily Flow _24&- gpd
Septic Tank Capacity ,,n gal Diameter _ in
Receiving Soil Type(1-6) 2 Number
Receiving Soil AppL Rate ¢od/itS Separation
Required Square Footage ic 0e3 W Orifices
Designed Square Footage moo^ feTotal Number of Orifices
Percent Reduction Taken Diameter n
Trench/Bed Width 3 ft Spacing in
Trench/Bed Length //'r6
Elevation MeasuhethenP `S Manifold
Schedule/Class
Original Drainfield Area Slope �� % Length 2 7 ft
New Slope if Altered % Diameter inDepth of Excavation from to Preferred Manifold Configuration Used? --M*es Q No
Original Grade (UP-Slope)
re
Designed Vertical Separation r9 in Transport Pipe
Down-slope) Schedule/Class ft
2e in Length
Diameter er in
Gravelless Chambers Required? ❑Yes No ❑Optional
Pump Required? Yes ❑No Dosing and Pump Chamberf
S ecific 'bons Number an —
Doses/Day
Pump/Siphon at
P Dose Quantity —�
gal
Difference in Elevation Between Pump Shutoff and UppcM0,9 Chamber Capacity _4�—
Orifice: Pump Controls: Timer(or) Elapse Time Meter(circle if required)
f If Timer: Pump On Pump Off
Uppermost Orifice is RHigher, Q Lowery Pump Shutoff
Capacity Q Total Pressure Head: � Check a following components if they drain between doses:
.gpCalculated Total Pressure Head: _ '_ ALaterals ptManifold Q Transport
(Attach Pump Curve)
DESIGN FORM- PAGE TWO
.MINwp :; . a. �4y iced Felxuy.18,
Scaled Plot Plan Scaled Layout Sketch Cross -See on Sketch
Test hole locations
.' Drainfreld orientation and layout Referenced depth from original grade:
perty lines Trench/bed dimensions and critical Septic tank lid and
andProposed wells within drainfield cover
Existing distances within Layout depth
100 ft of property lines BoxP`T / L"locations
O Critical distance measurements to cuts, Septic tank/pump chamber location Reference depth from original grade
anks,and surface water Observation port location— — and restrictive strata:
27 Location and orientation of curtain lean-out location Laterals,trench/bed to and drain and all absorption components Manifold placement p Curtain top
drain collector
.�.ocation and dimension of primary �Orifice placement O Sand augmentation
and reserve area teml placement,with distances to
r
gs edge of bed Oth cross-section detail:
on of slope indicatorAudiblelvisual alarm referenced Observation ports and clean-outs
nes Scale of drawing shown on scale bar
easements/driveways/
resource lands(if applicable)rrow and scale of drawingon scale bar
C1��p:.''s9ope sfiti�Styr[�lofl��et?<t�ttdti
Adl�litional Information
esign staked out
Operation and Maintenance Notice
Attached
O Waiver(s)Attached
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The undersigned designer❑does, does not a requirement to be notified by the installmadhhtbOffE �Sl.°ft.aR���)Set'e4�t V,
hours to perform a final inspection prior to ce r.
fEi ignbr Date Initials
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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: r ` /My�
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Environmental Health Specialist Date
Caution- DESIGN APPROVAL IS VALID ONLY UNDER TIIE FOLLOWING CONDPrION:
✓ 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: 3-11.,2002
✓ The system is installed by a certified installer,unless prior authorization is obtained from Mason County
Department of Health Services.
✓ Drainfreld site conditions have not been altered to adversely affect conditions of design approval
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Maintenance Inspections
Mason County is in the process of instituting a scheduled maintenance program.
Below is a schedule(subject to change)that they wish to follow. You will be notified
when such servicing is due.
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ON-SITE SEWAGE INSTALLATION
FINAL INSPECTION
11:7
DATE CALLED IN: ' � -'�I��(�-��� OI
TIME: /•�i f 0- yM�1�/,
INSTALLER: InJVnAI1,,y��-1 sJ `�-
APPLICANT/OWNER: I ' IW Iv n
CALLER: L
Ll
PHONE#OF CALLER:
SWG#:
PARCEL NUMBER:
i
SUBDIVISION:
Div: \ Lot:
SYSTEM TYPE(CHECK ONE): ❑
PRESSURE GRAVITY
INSPECTION SCHEDULE(CHECK ONE): )4 ❑
APPOINTMENT PLUG IN
AS-BUILT ON-SITE(CHECK ONE): IN ❑
YES NO
STAFF INITIALS:
/�, J$FI STAFi<Us,�ONLY
APPOINTMENT DATE: I -[ TIME: d ,
COMMENTS:
ON-SITE SEWAGE INSTALLATION
STAFF INSPECTION REPORT
........... ...........cwlsr
........
........
Yes No Continents
1. SEPTic TANK
A) >5 ft.from foundation? V
B) >50 ft from wells and surface water?
Q Bldg stubout to septic tank:clean-out if not 1-2%7
D) Baffles intact and clean?
E) Dividing wall intact?
F) Risers installed for access?
11 D-Box Leveled with water and/or speed leveler(circle)? a
Ill. DRAUVIUD
A) >10 ft from foundation and>5 ft from perceived property lines? ✓
B) >100 ft from wells and surface water?
C) >10 ft from potable water lines?
D) Laterals level to+I inch&end caps present if not looped? fAO
E) Gfirvelless chambers utilized? AI
F) System dimensions the same as shown on the design?
G) Gravel clean,properly sized,and proper depth?
H) PREssuRE Sysmus
1) Sand quality ASIMC-33? a
2) Head height uniform and k24 inches? 1z
3) Clean-outs and observation ports present?
4) Mound: Side Slope 3J?
5) Owner informed electrical connections must be made
by owner or licensed electrician and inspected by L&I?
IV. PUMP/PUMP CHAMBER
A) Screen basket one)installed? ✓
B) Riser installed for access? .7-
C) Alarm installed?
D) Pump on timer ofa SRwndle)? —V7-
V. As-BuiLTREQumm?
4- -K,-
uv4ir 1AA-kl J 24 AIA
The undersigned has reviewed this installation and verifies these findings on behalf of Mason County Department of Health Services.
or k
S4hitarian l Date
CAMYFiles\fi=lchec1Lwpd
Revised 9/26/97
AS-BUIL Revised February 18, 1998
PARCEL IDENTIFICATION
Applicant AA1 T�j Assessor's
./ Parcel # n s i_ 4) -31 — j4_3
Permit Number SWG �o`�Yp�1nee �(Twelve-Dlgit Number)
Installer �mn �V Y\ " Subdivision (N D o
Designer _ )C ells 11 LT_ D '
INSTALLER CHECKLIST
N/A es rior omp a on'
I. SEPTIC TANK v
A) >5 ft.From foundation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
B) >50 ft from wells and surface water? . . . . . . . . . . . . . . . . . . . . . . . . . .
C) Bldg stub-out to septic tank: clean-out if not 1-2%? . . . . . . . . . . . . . . . . . L
D) Baffles intact and clean? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . r
E) Dividing wall intact?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ✓
F) Risers installed for access? . . . . . . . . .
G) Tank Size: J..Z D gal.;Manufacture ALZ-,15
II. D-Box 1/
A) Leveled with water? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . —
B) Speed leveler used? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . —
III. DRAINFIELD
A) >10 ft from foundation and>5 ft from property lines? . . . . . . . . . . . . . . —
B) >100 ft fi-om wells and surface water? . . . . . . . . . . . . . . . . . . . . . . . . . . . .
C) >10 ft from potable water lines? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D) Laterals level to±I inch&end caps present if not looped? . . . . . . . . . . . 7
E) Gravelless chambers utilized? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
F) System dimensions the same as shown on the design? . . . . . . . . . . . . . . . .
G) Gravel clean,properly sized,and proper depth? . . . . . . . . . . . . . . . . . . . . ✓
H) PRESSURE SYSTEMS
1) Sand quality ASTM C-33? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -
2) Head height uniform and z24 inches? Actual head height
3) Clean-outs and observation ports present? . . . . . . . . . . . . . . . . . . . . . ✓ —
4) Mound: Side Slope3:1? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . —
5) Owner informed electrical connections must be made by
owner or licensed electrician and inspected by L&I? . . . . . . . . . . . . . L
IV. PUMP/PUMP CHAMBER
A) Pump make 41 Xz vwo -W/' Pump model -jS
B) Chamber size / 25 O gal; Manufacture A71 4f
C) Height of pump off bottom of pump chamber Co inches —
D) Pump chamber draw-down gallons per inch
E) Pump capacity gallons per minute
F) Pump controls:Timer(or) Elapsed Time Meter (circle if installed)
If timer is used: Pump On Pump Off —
G) Screen basket or ffluent filte (circle one)installed? . . . . . . . . . . . . . . . . ✓
H) Riser installed for access? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I) Alarm installed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
AS-BUILT DRAWING
CHECKLIST
If Drainfield&manifold b
orientation & layout ,
Iff Trench/bed dimensions 4 r'dA
and critical distances
within layout
4-7
Q Septic/pump tank pgr5
placement.
r
R� Location of buildings.
0� Observation port&clean- G•c ('v��J f
4
out location.
W Location of wells&
roads.
RRD�
E( Undisturbed native soil
between trenches.
c z 1`
O"North arrow l gN9Do �Z 'r
612/1/6,0
CAUTION:Minor adjustments to septic tank location and draintield orientation made in the field by the installer are generally acceptable to both the department
and the designer,but could in certain cases compmmise the viability of the system. It is the installer's responsibility to obtain pnor"Men approval from either the
health department 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.
CERTIFICATION OE INSTALLATION
Installer Check a box from Row"A" and'B",sign and date the certification
A. ❑ I certify that I installed the system without any 4--rcertify that all deviations from the design stamped
deviation from the design stamped"APPROVED" by "APPROVED"by MCDHS are shown above.
MCDHS
B. (2f,-t 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 installer ertification.
11-/6- 77
lg re� sta er Date
The undersigned approves this installation on behalf of Mason County D arar}ent of Health Services.
$ an ate