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HomeMy WebLinkAboutSWG97-0731 - SWG Application / Design / As-Built - 11/10/1997 PERMIT NO. SWG MASON COUNTY DEPARTMENT OF HEALTH SERVICES � • � N 426 W. CEDAR/P.O. BOX 1666/SHELTON, WA 98584 Date PHONE (360) 427-9670 Receipt No H Amount$ Z f DATE: y� m G. ���f_ —h/( / �? CHECK APPLICABLE ITEMS m M III ADDRESS:/ / DAYTIME PHONE: NEW SYSTEM o {� ?DRESS: (p REPAIR SYSTEM `2 CITY. STATE: ZIP: MAINTENANCE REVIEW Qq/ lv SINGLE FAMILY PROPERTY ADDRESS: OTHER Z SPECIFY: 3 SPECIFIC DIRECTIONS OR LOCATING SITE: PRIVATE WELL COMMUNITY WELL/PUBLIC SYSTEM I('' SYSTEM WFI# IN !%✓ L � Zel — e { SYSTEM NAME 191 Z— _d i APPLICANT NAME Name of Lot 72-h ft.x Z--7 ft. MAILING ADDRESS Installer I/ I Size: acres — Q Name of TELEPHONE z g v Number o SIGNAT� C? Designer Bedrooms X PLOT PLAN Draw dire I plot plan, I including: IJ � � a ❑Precise on test W h holes,s&pblg C-) measurad4sta to t U I propertyTo'1'inda�s. Q nI ❑Entry re�d;�other�oads,y jle 2 S drive O c / NOTE: `"OT DRAVaN M DESIQ1 C- /"! AR S°, 4 &9X -e a OFFICIAL USE ONLY. DO NOT WRITE BELOW DOUBLE LINE. SOIL LOGS /R'"Ysf*7�/ .2 o -/ya � a - V.2 lo4,�y5� � Y0p'0Q CDO/SP S¢a Ies �(v(l �'�IrSN s4n� —�%p7 7 /YIF�SG �raupJ yyo + e �q a✓2J G�— /Q lvwrsa sv Ilve DESIGNER DESIGNATION SCORES MINIMUM SYSTEM REQUIREMENTS Finding Score Designer Level: p One )IfTwo Soil Type Soil Depth n. 1� Septic Tank Daily Capacity: 1200 Gal. Flow: 360 GPD Slope % o Appl. O Infik. Parcel Size = Ac. Rate 0. U GPD/FT' Area ,,o FT' Distance to Shoreline 7--)aQ ft. Total Inslooptor ate COMMENTS/CONDITIONS FOR AP OVAL •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 she requirements(i.e.RLC,Water Adequacy)have been met. •Any change from the specified use of the property or arty site alteration affecting the system design may invalidate this permit. •This perms expires 2 years from the date of sae review.Denial of this permit may be appealed to the Health Officer within 10 days of denial date. SITE R DESIG REVIEW: proved Not Appr v INSTA TIONS ed of App ATE:// TE:/ PJE TE; IeV r3 TOP: Health Dept.Copy MIDDLE: Desi er's Copy BOTTOM:Applicant's Copy I1FSI.tiN i'h1tM - PAGE ONE A design will a e a when 3 cooietl bf iaeh of the folloiririg LE6" &to subsitteal gn form that has been signed and dated 0 �Uj 14`ro l.eted ource Lands and Critical Areas Checklist httac6d U scalelot plan, including all applicable items on checklist 1U ©,• a ayout sketch, including all applicablt items on checklist C o .s-section sketch, including all applicable items on checklist F UT� p"CBL IDnfttttCATION . . II y Imo. permit Number 1 ' ran I Designer's Name a� I II ' 1 �1 prop. Owner's Ndme Applicant's, Name �,4; + No'N`L�----- Mailing Address — t I Mailing Address �Ie 7S t�q 1 subdivision Assessor's Parcel No. e—pT1111EtY7' I -- DSSIGH PAWNTSPS Rnesigried Vattieai nI Atibili Mound subsurface Pressure Gravity Bed Ttlrich I @eptie Tank/Drainfiald Specif3ications pressure Distributitlri? t_1 Y!e No No, Bedrooms 4-ti ftnu::;:u:33 (if ytls: pteeeld. .? !l;;;;?? Daily Flow a p Septic Tank Capacity - i Receiving Boil Type (1-6) d f � L$t����th$8rV(C85 I Receiving Soil Appl. Rate Trench/b" Bottom Area f ' ScheduleHlpolDtlnty e �_ Trench/*" width ft Length APPROVE Trench/Cad Length 1 m ft Diameter Initials L Elevation Measurements #umber original Drainfield Area Slope k separation Date Drainfield Area Slope if Altered 3 otitiess I Total Number of Orifice@ in D.pth of Bottom of Trench/Bed � spacing from original Grade �P;�e��P� in 1d@fiifold Schedule/Glees Et ALength in Infiltrator used? Yea No Diameter Y'tsii@pbYt Hoo APump Reguired? u yes No Schedule/Clash — _ft N i (If yes. Proceed. .l • '••s .:::: ;! Length Diameter in ptwo/siphon specifications Dosiaq slid to" dlililsi Difference in Elevation Between pump shutoff N bows/Day tral and Uppermost orifice ft bo@e Quantity Cal Chambtr Ca0arity Uppermost orifice is 0 higher, lower w Check the folltlwittg colnpotteHEN it they dtain than Pump shutoff Capacity • Tot. Ares. Read aDm between dose@f I Calculated Tot. Pres. Head ft El t i• 1raH@ btt I (Attach Pump Curve) Laterals Manifold b f)F,MN FORM - PAGE TWO _ aa.1.0 o�iz.ns - - DESIGN CHECkLISTS t - Scaled Layout sk6tch Cross-section sketch p Scaled Plot Plan I Rafarenc6 d6pth from OYig- h �Yj I Drainfield orientation I inal grade: N Test. hole locations I Property lit, and layout fGl septic tank lid And �1 nes IN Trench#AWILdimensions and drainfield cover depth critical distances within Existing and proposed layout Reference depth froia Orig- p U wells within 100 ft y inal gradb and raatridtive p of property lines fC] 4nL D-Box/"T"/"L" locations i strata: � Critical distance I t� gae fIT /pump chamber Laterals, trench/bed 0 q measurements to cuts, i Sep rc q location top and bottom banks, surface water fl n Q ikl Location and orientation I � Observation port location Curtain drain collector A of WN all Sand augmentation M absorption area I [f Cleanout location components I Manifold placement No exterhal t6ket6nob noodede� � p I + Location and dimension t�placement Observation ports and p eC primary system and I orifice p cleAnoutg II 1 resetve area I with Lateral placement, yl I distances to edge of bed Additional mouftd informAtion+ .�� Buildings bl I ��Audible/visual alarm Upalope and downslope Directionu of slope indicator I / referenced fill width II p Scale of drawing shown Settled cap depth At p Q WaterlinesI I center and edge of bed M on scale bar LFJ Roads/easements/ I - ds/easements/ h driveways/parking Additional Mound Informations I gidewal2- slope MJ Critical resource lands I jEndalope width Up/downelope bed el#vat. (if applicable) Overall fill dimensiogs Cottlblatid RaatlNtca L�f1ds and checklist North arrow and scale of I Critical Aiiai drawing shown on bar �--_— DESIGN APPROVAL The undersigned designer does, N does not, waive the regirement to be notified by the A installer of the installation an given 40 hours to perform a final inspection prior to h cover. t�� �. 12-- �Z „ The undersigned has revi�� nd�a9neiecdeeign on behalf A Services. Q„ � � "PROWLi CInitials GUTION: DRSION APPROVAL 19 VALID ONLY VNDER THE rOLLOWINO CONDITIONgt Date p THE DESIGN IS STAMPED 'APPROVID0 EY MASON CotlNTY f1S"A1!' U"t 13P " ItAftCks EA J THE ON-SITE SEWAGE PERMIT HAS MOT EXPLRED1 EXDiRA"ON 6E >lAltl 4aR1iI1 to "at Op- THE DATE OY INITIAL SITE INSPECTION, MoT ON THE b"t o! blot" APPit"AL N THE SYSTEM IS INSTALLED BY A CERTtriab INSTALLER, WINS Molt At?f#.61t1tJL"0N IS AL OBTAINED FROM MASON COUNTY DEPARTMENT Or HEALTN SERVICES '� Howe�ts w/rn+irJ Ioo R. of tYRgINN0.v Mason County Dept. Health Services APPROVED Initials mlf"ARY 3®sctEA. Rr°SE RVE: 3 A W�E#• ssMC TANK � —*5 swfE s, GnegGE ?p4y-10 35 �RlvSwgy qe' waTCW� W _ �YLS�LLLAK ?eJ oF Z ` UIST. BOX S4EEU I EUELf2S GgsERwMn� 91 41M.TI(2*-r LINF�S) Mason County Deptces APPROVED Initials Date �i 9 P1N14H L Ii CGVFK �U f�wx• .. F.V1wFERFi _ — It IOC„ (p DWNNIWCX� • 36 ' TO TYPE Ih SOIL I l� CRASS-GEtT7APl � 1`� = � ± i �1�OOKIN6 NnerH1 A[L65S RN-OyT RISER ILOO 64A.L 2 commt.T(nta*PT lD PRIMNF1BLp SErnr_TNNK ET-FL V rWT TH OSP, SEPT►G T IC GQeSS-SFLjZ/y( (�t7 kp te) LA4vrRPek �► ArbUr f, S_YS7N'm UIM- EGT1j1M S 'P&� 2,of Z G ajAt Nmyb ON-SITE SEWAGE INSTALLATION FINAL INSPECTION DATE CALLED IN: ll TIME: INSTALLER: tax APPLICANT/OWNER: CALLER: PHONE#OF CALLER: SWG#: 7�' 7 PARCEL NUMBER: O 73u 7 b� SUBDIVISION: Div: Lot: SYSTEM TYPE(CHECK ONE): O PRESSURE G VITY INSPECTION SCHEDULE(CHECK ONE): ❑ APPOINTMENT PLUG IN AS-BUE.T ON-SITE(CHECK ONE): YES No STAFF INITIALS: p' + STA1E 'IISTfiIl.'t" APPOINTMENT DATE: TIME: ' v COMMENTS: ON-SITE SEWAGE INSTALLATION STAFF INSPECTION REPORT I. SErrlc TANK Yes No Comments A) >5 ft.from foundation? X 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? d IL D-Box Leveled with water and/or speed leveler(circle)? BL DRAPRIIErrl A) >10 ft from foundation and>5 ft from perceived property lines? B) >I00 ft from wells and surface water? C) >10 ft from potable water lines? _ — D) Laterals level to±1 inch&end caps present if not looped? _` E) Gmvelless chambers utilized? ---x - r F) System dimensions the same as shown on the design? ^ — G) Gravel clean,properly sized,and proper depth? t - H) PREssURE SYsTEms _ - l 1) San ity ASTM C-33? 2) Head h ' t uniform and z24 ' — 3) Cleanouta obsery >an resent? 4) Mound: Side 3:17 — 5) Own ed electn lions must be made _ by owner or licensed electrician and inspected by L&I? IV. PU11P/PUMp ER A) Screen t or etflu ilter(circle one)installed? B) Riser install f cress? — C) Alarm' — D) timer or and(circle)? V. AS-BUILT REQUIRED? - VI. OTHER COMMENTS/OBSERVATIONS The undersigned has reviewed this installation and verifies these findings on behalf of Mason County Department of Health Servic I^. Sanitarian bafe C:1MyFileslfaralchedcwpd Revised 9/NW AS-BUILT FORM Applicant's Name Assessor's Parcel No. 3Z I�,Y ,TrAge Permit N Installer'suNamember W _ Subdivision Designer's Name . 777777 C N/A Yes Pnot to Comp ehon` I. SEPTIC TANtt A >5 ft From foundation? B >50 ft from wells and surface water? — D 13!1 1'dsep�t?ank.clean-out if not 1-2%7 — E Dividing waII intact? — F Risers installed for access? — II. D-Box Leveled with water andl4ripecd leveler c le)7 III. DRAINBIELD — A >10 It from foundation and>5 ft from property lines? B >100 It from wells and surface water? — C >10 ft from potable water lines? D Laterals level to+1 inch 4 end caps present if not looped? — E GraveIIess chambers utilized? — F �dimensions the same as shown on the design? — PREssmeaSysProperly sized,and proper depth? — 1) Sand qual17ASTMC-337 2 Head height uniform and z24 inches? Actual head height_ — 3 Cleanoti and observation ports present? — 4 Mound: Side Slope 3:17 — 5 Owner informed electrical connections must be made by — owner or licensed electrician and inspected by L&I? rv. PtTW/PtW CHAMBER p make B Screen basks ore uea cic le one)del — C Riser installed for access? — D Alarm install — E Pump gallons per minute — F Pump on timer or deman circ e — . 1 If timer:Timer Oa Timer Off �— \ 2 i a 4� _.. .::�ii\ .dv. u..Y.?fur x�:x[$.6,."P_ ♦ w �. .!:: f� CHECKLIST yP Dsainfield&manifold orimustion bb�s &layout DI Tswchlbed dimensions and \ \ aitiW distance within layout Q Septidpump tank plac«n t2$t s alocation of buildings. ® Observation port&clean-out r� location. Ol locatimotwa.&roads. lD'Doll �,f70� �,^,� ® Undistusbed native soil between ZT 1 rVF bunches. SEPTIC TpNk North arrow • i I T31o=TUTi� FIC o 8' NouSE GARAGE uric:4o�a ��Du1;.Tioti1 TRKE� `N U� r 1 �C�i!!!!f/ON.•Mirror dJiubrien4 ro rapde tank locadon an dml rNoge ai ♦In )bfdb d�a I Ilan arrgenera!!y = by.. deslg bur Coald �trras+pl aa�ara romlar thr Nabld a/�}y�r atrninta/rep f lotto a tbldry to bfyn prlg / and the departmrrrt or the�utgno ogorr ning arty dMonona�iorim thengn ekat rha �y,,Soy e�avtadorulrem fhaa�� amst i abo,= .: :ate ✓a�.�::s .« w.'a .; ,. ., ,�'%'> Y'�° a: ����. e°• � Tortes her. Chlecc�k�a[b�,otx�from Row A'•and•'B srg�n�antd dat�e�the certification ce��. ¢�}hd doin ~ from tfie desr�tatempPittovPo"by M�CHSviation �APPRbvPo by amehtiwlt B Ipen'o teat I coon uptacte the �and left the system ��not tact the open or tBaoptemcah�on up to 48� or to cover. � glut what then A� �� e�e Iw�j�ycause ford int ate suspon ension oof my usmsf ffe,ice a tin8txhintI understand that if the inf lion soli hetCifr Is tWt AC6iit E,Qtgt! s eo�.r.y� The undersigned approves this installation on behalf of Mason County Department Health/Sgvieces�