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HomeMy WebLinkAboutSWG2000-00093 - SWG Application / Design / As-Built - 3/16/2000 Mom PERMIT NO. SW m MASON COUNTY DEPARTMENT OF HEALTH SERVICES Date o 426 W. CEDAR/ P.O. BOX 1666/SHELTON, WA 98584 Receipt No. PHONE (360) 427-9670 Amount$ m PR _ES OW DATE: 6 Q CHECK APPLICABLE ITEMS �/ m '� — b NEW SYSTEM MAILING AD RESS: / DAYII PHONE: L L C—��!/ A' �J� REPAIR SYSTEM TABLE 6 REPAIR m CITY' / STATE: ZIP' MAINTENANCE REVIEW m A.7 SINGLE FAMILY c PROp�RTY AD ESS: Z OTHER: /� PRIVATE WELL SPECIFIC DIRECTION$FOR LO�TING SITE: L COMMUNITY WELUPUBLIC SYSTEM � L SYSTEM WFI N I W i'✓ SYSTEM NAME M " ..1 IN APPLICANT NAME � IZ Name of Lot l�ft.x /D ft. MAILING ADDRESS O I W Installer Size: acres TELEPHONE 2 <: I r� Name of ) um er o SIGN RE o Designer .q 49' edrooms X = OFFICIAL USE ONLY BELOW THIS LINE DEPARTMENTAL SOIL LOGS DEPARTMENTAL COMMENTS/CONDITIONS M m TR IQ) G L S I— V44 S-*Or^6 � rk Z 4J✓Un5 I�� (� � v SA\-Ad LtyK 1 A1 a ef - 60 O\`�s � , C r SOIL TEXTURE CODES: V=Very G=gravelly S=sand L=loam Si=silt C=clay E=Extremely INSPE OR(print A INSPECT ON SIGNATURE DATE PERMIT PIR TION DATE •All systems require ongoing operation and Maintenance(O&M)as specified in Mason Ciltunty n-Site Standards. •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-site sewage system design approval does not imply other building site requirements(i.e.RLC,Water Adequacy)have been met. •Any change from the specified use of the property or any site alteration affecting the system design may invalidate this permit. •This i[ it ears from the date of site review.Denial of this permit may be to e H ce wdhin 10 da s of denial d e. DESI REV APPROVAL BY: DATE: I ALLATION ED BY,: DATE: �P L� a cU It `il�� /0 17 00 TOP: Health Dept. Copy MIDDLE: Designer's Copy BOTTOM: Applicant's Copy MASON COUNTY DEPARTMENT OF HEALTH SERVICES Environmental Health Water Quality Personal Health PO BOX 1666 SHELTON. WA 98594 LOCAL(206)427-9670 BELFAIR (206)275-4467&4468 FAX(206)427-7798 DATE: cJ l �`W TO: L-L-4`{LQ" FROM: `Q,Ow\ 11�ev ��✓ RE: Designfor (5LVAJc Parcel# 3213 Z °1C�1�? gYour design for the above referenced parcel has been reviewed and is APPROVED. Your design for the above referenced parcel has been reviewed and is HOT APPROVED. It does not meet the requirements or needs additional information. - Revised April 24.1998 DESIGN FORM - PAGE ONE A design will be reviewed when 3 copies of each of the following items are submitted: s Completed d9sign forth that has been signed and dated a Scaled layout sketch,including all applicable Items on checklist a Scaled plot plan,Including all applicable Items on checklist s Cross-section sketch,Including all applicable Items on checklist pgRGEL fDENTIFlCATiQN OM ,O DO I Designer's Name: —6�O Permit Number: Designer's Phone#: 3 o_y Applicant's Name: Z` Assessor's Parcel No.: (Twewe-D' it Number) Mailing Address: ¢ �U% S>D �47R I £L Subdivision: � (Na,nelDiv sion/BioclJLot) city State Zip ;DESIGN PARAMETERS Treatment Device O Mound � Dratnfreld CJ Glendon Biofilter 0 Sand Filter 1M►(rr /T®1, O Disinfection Unit - Make/Mod�[: 11 v 0 Aerobic Unit-Make/Model: A�, ,^ Orainfieid Tye! 4 10t?G J$'Bed - O Drainrock PS� Q Pressure '0 Trench 0 Gravelles Chambers Gravity Laterals STAND S Septic TanWDrainfieldSpecification3 Schedule/Class , g Number of Bedrooms 3 6O d Length in Daily Flow 0 Diameter 3 Septic Tank Capacity Number —J ft Receiving Soil Type(1-6) y O d1frz Separation Receiving Soil Appl.Rate O ftz Orifices Required Square Footage D ftz Designed Square Footage _&-� To umber of Orifices �� m Percent Reduction Taken ft Diameter in Trench/Bed Width ft Spacing Trench/Bed Length old Elevation Measurements Schedule/Class ---� a ��--� Original Dtainfield Area Slope 7�� Length in New Slope if Altered _ Diameter Depth of Excavation from in Pr ed Manifold Configuration Used? ❑Yes . Original Grade (Up-elope) in Transport Pipe 457E (Dawn-slope) Schedule/Class 9 Q gft in Length Designed Vertical Separation Diameter Gravelless Chambers Required? ❑Yes e Optional ---_i2sin2QPumpChamber Yes No 7_7Number of Doses/Day Pump Required? '"---- - _= at Dose Quantity pump/Siphon Specificati s - ---,._�--. at Between Pu utoff and Uppermost Chamber Capacity Difference in a ft pump Controls�umef(or) Elapse Time Meter(circle if require`dj Orifice: IfSimer:�purnp O❑ , Pump Off Uppermost Orifice ' Higher, Lower am Pump Shutoff �! e°m Check the following components if they drain between doses: Capacity @ T Pressure Head: -k tcrals anifold ransport Calculate oral Pressure Head: Pump Curve) DESIGN FORM - PAGE TWO Reviscd April 24, 1998 DESIGN CHECKLISTS Scaled Plot Plan Scaled Layout Sketch Cross -Section Sketch IN Test hole locations 3 Drainfield orientation and layout Referenced depth from original grade: O Trench/be�c .dimensions and critical R Septic tank lid and drainfield cover Property lines Existing and proposed wells within distances within layout depth 100 ft of property lines 01 D-BoxP`T'PL" locations Critical distance measurements to cuts, Septic tank/pump chamber location Reference d restrictive strata: from ro original grade banks,and surface water ® Observation port location and Clean-out location �A Laterals,trench/bed top and bottom Location and orientation of curtain Curtain drain collector drain and all absorption components anifold placement and augmentation 10 Location and dimension of primary Orifice placement system and reserve area ;4 Lateral placement,with distances to edge of bed Other cross-section detail: 0 Buildings Observation ports and clean-outs A Direction of slope indicator -S—Audible/visual alarm referenced �1 Waterlines I9 Scale of drawing shown on scale bar !Cross-section information for mound 15 Roads/easements/driveways/ parking L out information for mots stem system: Critical resource lands(if applicable) OVe ai s O Settted'cap deptft at center and edge of P3 North arrow and scale of drawing 0 Up downslope, [{slope bed shown on scale bar 1 1 width O Sidewalls[ope i0 Up-slope and w donslope bed elevation Additional Information 0, Design staked out Operation and Maintenance Notice Attached Waiver(s)Attached III ''Jill DESIGN APPROVAL The undersigned designer does, 0 does not, waive the requirement to be notified by the installer of the�S latioiil'and given 48 hours to perform a final inspection priorEtocoer: o l Sign ur f Designer ate 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: Environmental Health Specialist Date Caution: DESIGN APPROVAL IS VALID ONLY UNDER THE FOLLOWING CONDITION: ,/ The design is stamped"Approved" by Mason County Department of Health Services. Z1— ,/ as not expired,the Permit Expiration Date is: The On-site Sewage Permit h The system is installed by a certified installer, unless prior authorization is obtained from Mason County Department of Health Services. / n altered to adversely affect conditions of design approval Drainfield site conditions have not bee /�1 i �L�so�i Rd /P �v 6t.s/ If £L'A w F j fit l O ' // APPAOX rM/IT£- FG//S i, WOO 5£. I CA t \ u N V7 0 N W24 I Adel o O 0 A HeaR..O DE VE MAY 7ii6o �o� 3g PSD I i rJ I ®4p o , WC N1, t: i I a 41cppA� (A mi _ I_ i � FL:�1,1 b �o x V � N aLj� yI C n ON—SITE SEWAGE INSTALLATION FINAL INSPECTION is CtaeRtcuse. DATE CALLED IN: TIME: INSTALLER: APPLICANf/OWNER: V CALLER: ")Z S PHONE#OF CALLER: SWG#: PARCEL NUMBER: 3-- SUBDIVISION: Div: Lot: SYSTEM TYPE(CHECK ONE): El PRESSURE GRAVITY INSPECTION SCHEDULE(CHECK ONE): tA APPOIlJTMENT PLUG IN AS-BUILT ON-SITE(CHECK ONE): (Q YES No STAFFINITIALS: I A Ti STAFF USE©N!Y APPOINTMENT DATE: TIME: COMMENTS: ON-SITE SEWAGE INSTALLATION STAFF INSPECTION REPORT <STnF�t:>� trsr SErrrc TANK Yes No Comments I. 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%? % — D) Baffles intact and clean? � — E) Dividing wall intact? F) Risers installed for access? R. D-Box Leveled with water and/o�veler(circle)? III. DRAROMM A) >10 ft from foundation and>5 ft from perceived property lines? _I--- B) >100 ft from wells and surface water?! L — C) >10 ft from potable water Imes? — D) Laterals level to±I inch&end caps present if not looped? E) Gravelless chambers utilized? F) System dimensions the same as shown on the design? — G) Gravel clean,properly sized,and proper depth? p Q l H) PRESSURE SYSnMiS - v 1) Sand quality ASTMC-337 _ 2) Head height uniform and i24 inches? — 3) Clean-outs and observation ports present? — 4) Mound: Side Slope 3:1? — 5) Owner informed electrical connections must be made _ by owner or licensed electrician and inspected by L&I? IV. PUWIPUAW CffmvMER A) Screen basket or effluent filter(circle one)installed? B) Riser installed for access? — C) Alarm installed? — D) Pump on timer or demand(circle)?V. AS-BUILTREilunm? - VI. OTI[ERR COMbrENNTTS/ORSERVATLONS The undersigned has reviewed this installation and verifies these findings on behalf of Mason County Department of Health Services. �� •� svla loo sanitarian Date C:\MyFiles\inslcheck.wpd Revised 926197 A49-BUILT FORM !Blow ter Applicant �nn �.CK Parcel a 3 a/3 4f —13 - 7d/13 Permit Number SWG 2eeo - ad0°f q (TMWe-OlgitNumber) Installer �.e e �t / ^�'� Subdivision �� `� (N m iw� J t) Designer — ��a �"� NIA Yes Prior to Completion 1. SEPTICTANK V A) >5&From foundation?..................... ..... .. . .. ........ — B) >50 ft fiom wells and surface water? ... C) B14g stub-out to septic tank clean-cut if not 1-20/9? ................. D) Baffles intact and clean? ....... ................ ...... . . . ...... — E) Dividing wall intact?........... .............. . ..... . . . . . .... .. — F). Risers installed for access? ..... ...... v G) Tank Sim: i hV _ga-;Manufacture 1J i 1 11. D-Box A) Leveled with water? . ..... . ... .. ... .. . ... . . . . ... . . . . . . . .... . . . B) Speed leveler used? .. . ... ... . .. .. . .. . .. . . . . . . . . . . . . . . . . . . . . . . — 111. DRAINFIELD V A) >10 ft from foundation and>5 it from property lines? .. . . . . . . .. .. . . . ` B) >100 ft from wells and surface water? . ... ... . .. . ... . . .. . . ...... .. C) >10 ft from potable water lines? v D) Laterals level to±I inch&end caps present if not looped? ....... .... — E) rn�ess chambers utilized? .................. ...... . . . .. ... .. v �� S dimensions the same as shown on the design?.... . . .... ...... — V (3) Gravel clean,properly size4 and proper depth? — PRESSURE SYSTEMS 1) Sand quality ASTM C-337 ................................. — 2) Head height uniform and 2:24 inches? Actual head height — 3) Clean-outs and observation ports present? — 4) Mound: Side Slope 3:1? .................................. — 5) Owner informed electrical connections must be made by — owner or licensed electrician and inspected by L&I? . . . . . . . . .... . IV. PUMP/PUMP CHAMBER A) Pump make Pump model — B) Chamber size gal; MauufkFfim — C) Height of pump off bottom of pump chamber 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 u m On Pump Off _ Gj Sueen basket Went filter e6cle one)installed? to [riser installed for access ............. ..... . . .. . . ... . ......... . [ Alarm installed? ....... . ................. . . . . . . . . . . .. ....... . c � � i /813Ma a d DraioBeld do manifold }� d u S E orientation do layout } fl Tmachtbed dimensions S and critical distances n within layout GI Septiotpump tank placement. 5 6 Location of buildings, Alf ❑ Observation port&clean- out location. L ❑ Location of wells& ^� �t N e roads. ❑ Undisturbed native soil between trenches. ❑ North arrow CAUTION:Minor adjusbnents b upGe tank location and dninfield orientation made a rho fiord by the instiller are eaudl and tlu designs,but could a certain cases compromise the viabili of the s fem. It is the installer's g6 Y tazeptable to both the department he ammalth or the designer before making any dcvia .from the design that at2ct the respo�ibllity b obfaa pray%naen approval from ertha the system viability. Any deviations from the approved design must be a � � 3izRTfF1G O F' tST/1 , Installer Check a box from Row"A"and"B',sign and date the certification A. IT I certify that I installed the system without any ❑ I certify that all deviations from the design stamped deviation from the design stamped"APPROVED"by "APPROVED"by MCDHS are shown above. MCDHS B. ❑ I certify that I contacted the designer and left the ❑ I did not contact the des' ner prior to final cover because the system open for inspection up to 48 hrs prior to designer waived the notillcation requitement. cover. I further certify that all information contained on this forth is accurate. I understand that if the information contained herein is not accurate,there will be just cause for immediate suspension of my installer certification. f pn �rgnarure of CY ate The undersigned approves this installation on behalf of Mason County re of eah Services, •, lv, anrtanan ate