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HomeMy WebLinkAboutSWG93-1316 - SWG Application / Design / As-Built - 9/28/1993 PERMIT NO. SWIG m D MASbN CO NTY DEPARTMENT OF HEALTH SERVICES g Date 3 y' o 426 W.•CEDAR/P.O. BOX 1666/SHELTON,WA 98584 Receipt No. o y PHONE (206)427-9670 Amount$ z f m m CHECK APPLICABLE ITEMS ✓ m 0 MAI AD RESS: D YTI PH E: INSTALLING NEW SYSTEM m REPAIRING OLD SYSTEM Cl STATE: EXPANDING SYSTEM m SINGLE FAMILY ✓ PROS R ADD SS: OTHER 2 SPECIFY: 3 SPECFFI DIRECTIONS FOR L ATING SITE: PRIVATE WELL CD PUBLIC SYSTEM ' SYSTEM ID NUMBER L SYSTEM NAME p , APPLICANT I ' NAME Name of Lot o70 C ft.x ft, MAILING ADDRESS P O !3 Installer o ze: acres TELEPHONE t7(g 2(s- 6, <, Name of SIGNATURE o um er o C Designer Bedrooms X PLOT PLAN Draw a dimQpeieneF_p(ot pl ! X ro including: U v X 46-1 l ' A ❑Precise lowtl o t > �g holes,sh W measur cis to LLI property b 649- y J r ❑Entry road@!�Or r Wds, � Ga aye � driveways,_, N wW NOTE: SOWGIfyy� I6)S y �tFE�Ar9 rI OFFICIAL USE ONLY. DO NO'FQ` � "SW d U�LE LINE. # 7 SOIL LOGS _ ' po�Kcls x�ed o-�o" � � �o� o-sz Lo� sI o-3a� —l ° cab S,14 3-LIof � 3 d O 4A aAAra ,,qad — I Oak cov.I 'qvd A.5e - ca1I S'lkAd AIAJ yv}.ve.l- 1005c Depth from Original C o-jw4io Grade to Restrictive 00A Layer or Water Table: In. DESIGNER DESIGNATION SCORES UM SYSTEM REQUIREMENTS Finding Score Designer Level: ne ❑Two Soil Type .e� Vertical Separation 3 in. Septic Tank Daily P �- S Capacity: IeGal. Flow: 3 GPD Slope —'� Appl, ��( +�4rtkd Infilt. Parcel Size 2 Ac. Rate GPD/FT' S' Area FT' Distance to Shoreline —ft. Total Ins or Date q- —Q3 t COMMENTS/CONDITIONS FOR APPROVAL s w-u5VMVA—V �, VVAI ta- mR ui, ,red 0" (31MV44 Any change from the specified use of the property or any site alteration affecting the system design may invalidate this permit. This Permit expires 3 years from date of site inspection.Denial of this permit may be appealed to the Health Officer within 10 days of denial date. :)(Approved )(besignRagired ❑Not Approved DESIGN: Approved ❑Not Approved INSTALLATION) roved ❑Not Approved DATE: (...`cj,G BY:P, DATE: 210`1f TOP: Health Dept. Copy MIDDLE: Designer's Copy BOTTOM:Applicant's Copy i DESIGN FORM - PAGE ONE a�i.ed 09/17/93 A cjesign will be reviewed when 3 copies 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 + 5 PARCEL IDENTIFICATION Permit Number nn Designer's Name o� � � Applicant's Name ineW/J 6-),In /SPPrC�$fop. Owner's Name OV ) Mailing Address p C) f3r;x ''�L(I Prop. Street Address 66 e12r11j1)62CeM22S9eC1C ,U C it� Ststw Zip Y Assessor's Parcel No. Subdivision Masun �U�ii.; _:�,i, ficanil Lei CBS � (•i'valva-Diq l< Number) (Nsn.a/Divi� o � qq DESIGN PARAMETERS Date Designed Vertical �( �f Separation Mound Subsurface Pressure Gravity Bed Trenchy in ( th Is r Septic Tank/Drainfield Specifications No. Bedrooms Pressure Distribution? Yes No Daily Flow ,�i .,n 9Pd .....................E (If yes, proceed. . . ) ............................................. Septic Tank Capacity ( �('j(} gal Receiving Soil Type (1-6) �. Receiving Soil Appl. Rate /, 'a gpd/ft' Laterals Trench/Bed Bottom Area �Qn ft' Schedule/Class Trench/Bed Width 3 ft Length ft Diameter in Elevation Measurements Number Orig. Drainfield Area Slope (� 9 Separation ft Final Drainfield, Area Slope (� Orifices Depth of Bottom of Trench/Bed Total Number of Orifices from Original Grade �� in Diameter in "p'S�pe Spacing in Manifold Schedule/Class Length ft 9 Pump Required? EJ Yes No Diameter in ...................i (If yes. Proceed. . . ) ii...................... 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 « Doses/Day Uppermost Orifice is higher, Q.lowar Dose Quantity cal than Pump Shutoff Chamber Capacity gal Capacity @ Tot. Pres. Head gPm Calculated Tot. Pres. Head ft (Attach Pump Curve) DESIGN FORM - PAGE TWO Pe.ieed 09/17/93 DESIGN CHECKLISTS Scaled Plot Plan Scaled Layout Sketch cross-Section Sketch pul Reference depth from orig- Test hole locations ® Drainfield orientation final grade: FVand 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 9 D-Box/"T"/"L" locations strata: Criitical distance 11 measurements to cuts, ® Septic tank/pump chamber Laterals, trench/bed blanks, surface water location top and bottom LL%tion and orientation observation port location Curtain drain collector of curtain drain and all absorption area Cleanout location El Sand augmentation components ❑ Manifold placement No external reference needed: Location and dimension of primary system and El orifice placement El observation ports and reserve area ❑ cleanouts Lateral placement, with p� Buildings distances to edge of bed Additional mound information: 4F� Direction of slope El Audible/visual alarm Upslope and downslope indicator referenced fill width ElWaterlines Scale of drawing shown Settled cap depth at on scale bar center and edge of bed Roads/easements/ driveways/parking Additional Mound Information: Sidewall slope ElCritical resource lands El Endslope width El 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 d1vtNS li4 w:i APPROVED DESIGN APPROVAL Initials The undersigned designer 0 does, ❑does not, waive the reqirement to be notified by the installer of the installation and given 48 } rs to perform a final2 inspection prior to cover. iv+•cvr• � a•.san•� / The undersigned has reviewed and ppprOvedt is design on behalf of Mason County of Health Services. x•_aen x.+•yecoz a•c• CAPTION: THIS DESIGN IS ONLY VALID IF STAMPED "APPROVED" BY MASON CO. DEPT. OF HEALTH 0+� '�ie ld blot � la>1 ac�cr�s Tao, N 100 CMnberr� t110br1G � Hc+rn e sj S lope. r sac t� Fk��t Herne ,aR��Q�-qy lad Cran berry Creek Road c)raln -�le Id E--a:y0ut 10 TSh�I�nE race Ubs�rue{�gy Pcrt $. "Zl Bcx I H r y ro do- � YC r� r .A►PPROzJED���e, N3 O�Ser�ctct� t Initials_ Date j yS em Gross Sec+ON nle+al rope and Ter RQbrre. 7UirA a 1` t yr� ar; Grave I 4;, Grave) 6 Gra ve I aN°Sct�YA 04' Vu-hcal %SLpara6wN r FINAL INSPECTION - SEPTIC SYSTEM DATE CALLED IN: 1cp_ Q� �J TIME: �L ►�l �'� ✓� T V4 0 \Iq_� I INSTALLERfr� ��, dT_ )p APPLICANVOWNER: \ ) �—�Q- A A CALLER: PHONE # OF CALLER: ��C1- Ro o i �� ` �� (0�avJ ( yi„vwl uS swc#: LJuske� - 1a-Ioxp q:00 &,?(—r o1� PARCEL NUMBER: ca `C OU��� R� G(+wad SCGT� 0T SUBDIVISON: w c f ` � 1 -to 4w, fiV`49 ✓P!�}9-I14 �\�/'Q,N Division Lot I (o.}�,C4{' Oln reOVIJY k,4 PRESSURE or GRAVITY (Circle one) / APPOINTMENT or PLUG IN (/� Staff Initials (Circle one) FINAL INSPECTION SEPTIC SYSTEM CHECK LIST i YES NO COMMENTS I) SYSTEM TYPE A) CONVENTIONAL: (TRENCH / FIELD) _ B) ALTERNATIVE: (MOUND/SUBSURFACE) _ II) SEPTIC TANK A) > Five Ft . from Foundation _ B) Foundation-Tank Line Slope: Cleanout provided if not 1-20- C) Baffles Intact / Clean D) 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 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 _ 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 VII) AS BUILT REQUIRED COMMENTS Signature Of Sanitarian Date vised: 10/20/92 AS-BUILT, FORM - PAGE ONE Revised 07/12/93 PARCEL IDENTIFICATION Permit Number SWG9 3 Subdivision 1 (Mama/Divioiot./Hlook/Lot) Installer's Name ( JiT('� cif l a , Assessor's Parcel No. (Twelve—D191C Nv+nber) Designer's Name Q '1 INSTALLER CHECKLIST rA) TANK Yes No N/A ft from foundation? Xlding stubout to septic tank: cleanout provided if not 1-2%fles intact and clean?iding wall intact?A) aer leveled? 1 B) Speed levelers used? — III. DRAINFIELD A) >10 ft from foundation and >5 ft from property lines? — B) Laterals level to ±1 inch? — C) End caps present if not looped? — D) System dimensions the same as shown on the design? X — E) Gravel clean, properly sized, and proper depth? — F) PRESSURE SYSTEM v 1) Sand quality ASTM C-33? X 2) Head height uniform and >-24 inches? — 3) Cleanouts and observation ports present? 4) Mound: Side slope 3:1? — IV. POTABLE WATER LINES A) >loft from field or double sleeved? Xv- 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 Row "A," check box from Row "B," sign and date the certification. A. 0 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. B. F] 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 installe rtification. 9 vaatvra of � "teller D / e The undersigned approves this installation of behalf of Mason County Department of Health Services. tlealtp ir.apaotor D-aha AS-BUILT FORM - PAGE TWO Revised 07/12/93 Ei• PARCEL IDENTIFICATION Permit Number SWG93 - 1316 Subdivision �y � �/ (Nana/Oivialor�/HSoc)e/Lot) Installer's Name // //-!PILL/ Assessor's Parcel No. 3o2I3/o a C`L'�8"� (iwalva-Digit Numbat) Designer's Name !Pl CL AS-BIIILT DRAWING NC �� ll 2113 0 -r�"K 3� Deed x 2) d� ©Well 50� a 50' Nome ;� a op C • CAUTION: minor adjustments 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 in- staller'a responsibility to obtain prior written approval from either the health department or the designer before making any devi- ations 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 ® Undisturbed native soil and layout ❑ between trenches cleanout location Trench/bed dimensions and North arrow critical distances within Manifold placement p( layout ElICI Scale of drawing shown IVI Orifice placement on scale bar D-Box/"T"/"L" location ❑ Lateral placement, with Additional Mound Information Septic tank/puwdg-- r distances to edge of bed ❑ location ® Endslope width Ful Location of wells, roads ❑ Overall fill dimensions Location of buildings