HomeMy WebLinkAboutSWG95-0291 - SWG Application / Design / As-Built - 5/3/1995 MASON COUNTY DEPARTMENT OF HEALTH SERVICES PERMIT co SWG 95- c y
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426 W. CEDAR/ P.O. BOX 1666/SHELTON, WA 98584 Receipt IN o
PHONE (360) 427-9670 Amount$ '
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3 D
CHECK APPLICABLE ITEMS �/ 9
MAI ING ADD SS: Sf DA IME H E: NEW SYSTEM o
j 631 - REPAIR SYSTEM t°
C TY: STATE: ZIP; MAINTENANCE REVIEW
Q SINGLE FAMILY
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PROPERTY ADDRESS: OTHER Z
SPECIFY: 3
SPECIFIC DIRECTIONS FOR LOCATING SITE: PRIVATE WELL
r L. -tt tr COMMUNITY WELUPUBLIC SYSTEM r,
hCetC 110S �er, ,ry31 Sj �rSlynshl Shor+_ ii 6-0 SYSTEM WFI#
SYSTEM NAME O YN,i. -fur•n I� on Luilloc Lanc . A+ erg o{.rd. )oton rt Ip t APPLICANT ("
NAME (—
Nameof 1h1 t S-�-� '` Lot �jtn. 1 n MAILING ADDRESS ft.x .�JLft. � Pots� 1341
Installer I( �;
Size:
� acres o
Nameof TELEPHONE III
Designer um er o SIG RE // 11 0
Bedrooms 13 X /V
PLOT PLAN ) ./0
Draw a dimensional plot plan, 71i L
including: - X t/, a
❑Precise location of test . ` \ n, 0
�yYI
holes,showing
measured distances to - fIJ
property boundaries. N 00(loo,
❑Entry road;other roads,
driveways. ,� ` \ 7 c tom'
NOTE: DO NOT DRAW IN NI c
SYSTEM DESIGN ` Qf n,,,, :i_
LL-
�lL.fo � r I�u1 Q
OFFICIAL USE ONLY. DO NOT WRITE BELOW DOUbMtINE.
SOIL LOGS 9
a —36 u 970 el t7
CI�vL -
J sla 36 f --Ae " � ti
Depth from Original
Grade to Restrictive
Layer or Water Table: In.
DESIGNER DESIGNATION SCORES UM SYSTEM REQUIREMENTS
Finding Score Desi n LLevel: KOne ❑Two
Soil Type _y �C
Vertical Separation 4 Z Jr. -� Septic Tank Daily
Capacity: 12do Gal. Flow: 1�7) GPD
Slope Lis -I. Appl Infilt. `
Parcel Size ) q A. $� Rate (��� GPD/FT� Area 00 o FT2
Distance to Shoreline >2wft. _0�7" Total I Inspector Date
COMMENTS/CONDITIONS FOR APPROVAL
•All septic systems must be designed and installed by contractors certified by Mason County Department of Health Services, unless prior approval is
granted by the department,or the design is by a professional engineer.
•Septic permit approval does not imply other building site requirements(i.e. I Water Adequacy)have been met.
•Any change from th cified use of the property or any site alteration affecting the system design may invalidate this permit.
This Permit exp' ap ears from date of site inspection.Denial of this grimit may be appealed to the Health Officer within 10 days of denial date.
SITE REVIEW: DESIGN REVIEW:ftPlUved _j Not Approved STALLATION)6Approved ❑Not Approved
BY: DATE:d1:r_ BY: 41 DATE: f j1._ BY: 15 DATJ
�. TOP: Health Dept. Copy MIDDLE: Designer's Copy BOTTOM: Applicant's Copy
r
DESIGN FORM - PAGE ONE Revised 08/24,
A des w 1 e r wed when 3 copies of each of the following items are submitted:
p�J r esign form that has been signed and dated
�T � ii9 esource Lands and Critical Areas Checklist attached
u u Scaled t plan, including all applicable items on checklist
MAY 1 7 ed layout sketch, including all applicable items on checklist
s-section sketch, including all applicable items on checklist
gyEALTH SERVICE5
p PARCEL IDENTIFICATION � ) �-/
IIPermit Number �`'L�ftf: DZ �� Designer's Name NO�� //9/^' _�4
I� Applicant's Name /CA21G� ` CR���C�R Prop. Owner's Name i G L G. OCKeho
II Mailing Address �lf72a 7-21ts'" f .s"6' Mailing Address .7-
sr lWe
II I y 1 wbt�— O ,t /'s� G'qs °Zip
II Assessor's Parcel No. 3?-ZIY`i /� 9C070 Subdivision A400 ' Of %2e��U"-?/ /✓ 3T&l
II we ve- igi ung5er) �Nam'e7'»'V' s 7Lot7—
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II DESIGN PARAMETERS
II ✓ ✓ ✓ 4. ~'l�✓ j��BNICes
r—��/ V�
II u u u Ll (h+Yfalg w ion
De sert/ical
II Mound subsurface Pressure Gravity Bed Trench Date _ w�h 'f in
11 Septic Tank/Drainfield Specifications I n
II No. Bedrooms 3 I Pressure Distribution? U Yes No
u Daily Flow 3L0 and I:::::::::::::::::::::::: (if yes, proceed. . . ........................
................
II Septic Tarik Capacity O gal I
II Receiving Soil Type (1-6) I
II Receiving Soil Appl. Rate 06 0 cmd/ft2 I Laterals
11 Trench/Bed Bottom Area C O O ft2 I Schedule/Class
II Trench/Bed Width 3 ft I Length ft
1) Trench/Bed Length 1z ,00 ft I
11 I Diameter in
11 Elevation Measurements I Number
II Orig. Drainfield Area Slope 1S t I Separation ft
11 Final Drainfield Area Slope a 0 t I Orifices
II Depth of Bottom of Trench/Bed I Total Number of Orifices
from Original Grade /8 i I Diameter in
11 e I Spacing
II in I Manifold
u �uownslope I Schedule/Class
II 0 I Length ft
11 Infiltrator Used? Yes No Diameter in
11 n Transport Pipe
II Pump Required? u Yes �No I Schedule/Class Q
h...................... (If yes, proceed. . .) ........................331 Length ft
II I
Diameter 2 in
11 Pump/Siphon Specifications I Dosing and Pump Chamber
II Difference in Elevation Between Pump Shutoff I # Doses/Day
II and Uppermost Orifice ft I Dose Quantity cal
II t-1 r-i I Chamber Capacity cal
1) Uppermost Orifice is u higher, U lower
11 than Pump Shutoff I Check the following components if they drain
11 Capacity 0 Tot. Pres. Head com I between doses:
II Calculated Tot. Pres. Head ft I n n !(may/
11 (Attach Pump Curve) I U Laterals 1__I Manifold 9_' Transport
1
1
DESIGN'FORM '- PAGE TWO
DESIGN CHECKLISTS
I
II Scaled Plot Plan I Scaled Layout Sketch I Cross-Section Sketch
II I I
II I Reference depth from orig-
II Test hole locations I. Grainfield orientation I final grade:
II I and layout I
II Property lines I I [P Septic tank lid and
Trench/bed dimensions and I drainfield cover depth
II i� Existing and proposed I critical distances within
11 wells within 100 ft. I layout I Reference depth from orig-
II of property lines I I inal grade and restrictive
II le-1-- I LAf_D-Box/"T"/"L" locations I strata:
II u Critical distance I [:?o (pT fib! I F-
11 measurements to cuts, I Septic tank/pump chamber I Laterals, trench/bed
II banks, surface water I location III top and bottom I,
11Location and orientation I u bbservation port location ' Curtain drain collector
II of curtain drain and all I ��
II absorption area I Lf Cleanout location I Sand augmentation
II �mponents If II
II r� I "'—' nif old placement I No external reference needed: )
II Location and dimension I I rl I'',
II of primary system and 14w orifice placement I ervation ports and II
11 reserve area I I cleanouts p
11 I Lateral placement, with I I
II Buildings' I distances to edge of bed dditional mound information: ))
II I I r� II
11 Direction of slope I Audible/visual alarm I u lope and downslope
11 �fi?/indicator I � /ref�r enced I fil width
II Waterlines I u'�Scale of drawing shown I u Settle cap depth at
II ✓ I
on scale bar I center a d edge of bed II
II Roads/easements/ I I II
IIdriveways/parking I Additional Mound Information: I U Sidewall s e II
4� I
III Critical resource lands I u ope width I u Up/downslope be levat. II
II (if applicable) I i i I II
II I u overall fil nsions I Completed Resource Lands and
II �+ North arrow and scale of I I Critical Areas Checklist II
II drawing shown on bar
s�1y deft• Health
II DESIGN APPROVAL II
The undersigned designer does, L_Idoes not, waive the regire{�4tte�be notified by the II
II
installer of the installation an iven 48 hours to perform a final inspeZ!tion prior to
II cover. fs .S_
signature II
II The undersigned has reviewed and appr a this design on behalf of Mason County of Health 11
II Services.
ea ns c
II
II CADTION: THIS DESIGN IS ONLY VALID IF STAMPED •APPROVED• BY MASON CO. DEPT. OF HEALTH II
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7?1`7- °F 56N6 MASON COUNTYCAL
�J • °�' e �'' aFsp* 3zg DEPT. OF HEALTH
(-Z ACRTs �� 0Z t�
Field Sheet for SWG# !n i=Ff•�� I�-O��A �G�'IC�ZIL�� E-c�� Applicant Name:
Absence of critical area verified on subject property:
Yes No
1. Steep Slopes > K l✓ 2a o/ 1
15% � J
2. Water
a. Wetlands
b. Streams
C. Lakes
d. Ponds
—
e. Saltwater - -
Sanitarian's Signature Date
ON-SITE SEWAGE INSTALLATION
FINAL INSPECTION
DATE CALLED IN:
TIME: '-
INSTALLER:
APPLICANT/OWNER:
PHONE # OF CALLER• s Le `
PARCEL NUMBER: ��/�\n �'L L�I�-L� \LJ J �/""" �✓
SUBDIVISION: - W
DIVISION: LOT:
..........................................
TYPECHECK ONS.. • e............................................................................................
SYSTEM ..� ei ................................
GRiwITY .. ✓G ��
Fti 06 INSPECTION SCHEDULE (CHECK ONE) : -
t^,
APPOINTMENT PLUG IN V� D
AS-BUILT ON-SITE? (CHECK ONE) : r-I t-1 �700
u u ll..��
YES NO s
STAFF INITIALS: d"
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Revised 02/01/95
ON-SITE SEWAGE INSTALLATION
STAFF INSPECTION REPORT
I STAFF C88f31.IST
I I
I CONFIRMED RY INSPECTOR?
I i
I. SEPTIC Ta Yes No CammenG
N >5 ft frm foundation?
a) Bldg stubout to septic tank: clearwut if not 1-2%? n _
c) Baffles intact and clean? h
D) Dividing wall intact? x _
It. D-Ras leveled with(wat o sp inter (circle one)? _ 1
I III. DRna)rxim
ji.) >10 ft from foundation and >5 ft from property lines? K _ I-
1 R) Laterals level to t1 inch & end caps present if not looped?X _ 1
c) System dimensi ore the same as shown on the design? k
1 D) Gravel clean, property sized, and proper depth? _ _ wo 9'4vel 1
1 R) PRESSORR SYSTRw
I I) Send quality ASTIR C-33?
1 a) Head height uniform and 2:24 inches? _ x 1
1 3) Cleanouts and observation ports present?
1 4) Hound: Side slope 3:1?
1 5) Owner informed electrical connections must be made 1
by owner or licensed electrician and inspected by DLI? _ X 1
I 1
Iv. POTAWX mamm xmms
1 L) >10ft from drainfield, transport line, and septic tank? k _
I a) Hells >100ft mf� drainfield? K _ I
V. Pump
I N Screen:#4tget or effluent filter (circle one) installed? _ x
1 R) Risoek4l"tled for access? _ x
c) Manvn,installed? _ xc
i
I VI. ILI�9 3XT REQV=?
I
j vxi,;'.,dew errs
I
1 1
1 I
I
I I
- I
1
The undersigned has reviewed this installation and verifies these findings on behalf of Mason County of Health Services.
I 1
I
Ainspector 3Date
h:callin_w
Revised 02/01/95
AS-BUILT FORM - PAGE ONE Revised 12/14/94
II PARCEL IDENTIFICATION
II Applicant's Name - ✓ ff/� ^I ��
Permit Number SWC9 Subdivision
II — ame z.v sz. n/ oc c LoE�
II Installer's Name t n _ Assessor's Parcel No. -3�2134j44 0
IIDesigner's Name c r�nm
I II
N INSTALLER CHECKLIST �I
N/A Yes Prior to
I. SEPTIC TANK Completion II
II A) >5 ft from foundation? II
II B) Bldg stubout to septic tank: cleanout if not 1-2%? II
C) Baffles intact and clean? II
II D) Dividing wall intact? „� II
Ii. D-BOX Leveled with water and/or(speed leveler ircle)? II
III. DRAINFIELD II
A) >10 ft from foundation and >5 ft from property lines? II
II B) Laterals level to tl inch & end caps present if not looped? II
II C) System dimensions the same as shown on the design? II
II D) Gravel clean, properly sized, and proper depth? II
II E) PRESSURE SYSTEM duHrnr u
I) 1) Sand quality ASTM C-33? II II 2) Head height uniform and :24 inches?
3) Cleanouts and observation ports present? II
II 4) Mound: Side slope 3:1? II
5) owner informed electrical connections must be made by II
owner or licensed electrician and inspected by DLI? II
IV. POTABLE WATER LINES II A) >loft from drainfield? _
B) Wells >100ft from drainfield? II
II V. PUMP/PUMP CHAMBER
II A) Designed pump used, or specs attached for equivalent pump? II
II B) Screen basket or effluent filter (circle one) installed? u
II C) Riser installed for access? u
II D) Alarm installed? u
n S 11
q CERTIFICATION OF INSTALLATION _ N
N H II Installers Check box from Row "A,• check box from Row •B,• sign and date the certification.
s u
A. I certify that I installed the system u I certify that all deviations from u
b without any deviation from the design the design stamped "APPROVED• by MCDHS are H
II stamped -APPROVED- by MCDHS. shown on the reverse side of this form.
II B. I certify that I contacted the 1 �L I did not contact the designer prior II
N designer and left the system open for to final cover because the designer II
II inspection up to 48 hrs prior to cover. waived the notification requirement. II
U I further certify that all information contained on this form is accurate. I understand N
h that if the information contained-hereia' is not ac ate,' there will-be 3ust::cauae 'for
II immediate suspension of my instalAer ce tifica
II� a7195
I The undersigned approves this i6nktallation of behalf of Mason County Department of Health II
II services. II
II HgaMI €e �3 are
AS-BUILT FORM - PAGE TWO Revised 12/14/94
PARCEL IDENTIFICATION �I
Applicant's Name
Permit Number SWG9 S - Dos/ Subdivision I/JO�"I OT -���
ame lvislao//n //o!!c �lnE7)
Installer's Name Assessor's Parcel No. � ��x� �`1`• �Gv/Q I�
Designer's Name wed-IIfi u er II
I
AS-BIIILT DRAWING
G=Opy: Mimr adlustments to septic tank location and drainfield orientation made in the field by the installer are generally ac-
ceptable to both the department and the designer, but could in certain cases compromise the viability of the system. It is the
installer's responsibility to obtain prior written approval from either the health department or the designer before asking any
deviation& fron the design that affect systea viability. Any deviations from the approved design must be shown above.
II AS-BIIILT CHECKLIST I�
Drainfield orientation U Observation port location u Undisturbed native soil
and layout n between trenches
El
I Cleanout location r I II
Trench/bed dimensions and 11 I--I North arrow
H critical distances within U Manifold placement r 1 U
layout C U Scale of drawing shown
orifice placement on scale bar
D-Box/"T"/"L" location
II u I- I Lateral placement, with Additional Mound Information
Se
ptic tank/pump chamber distances to edge of bed n ��
location n u Endslope width II
U Location of wells, roads n
Location of buildings U overall fill dimensions
I �