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HomeMy WebLinkAboutSWG98-0496 - SWG Application / Design / As-Built - 10/5/1998 PERMITNO. SWGIM — rn a MAsSON.CbUNTYaEPARTMENT OF HEALTH SERVICES c m 426 W. CEDAR/P.O. BOX 1666/SHELTON, WA 98584 Date N PHONE (360) 427-9670 Receipt No. Amount$_aEN Z YYI• -lwves f!/• o I17a�/e owi /o CHECK APPLICABLE ITEMS �/ 3 CIS MAILING ADDRESS: DA IME PHONE: NEW SYSTEM 2 /0 p• 0 e 3e / REPAIR SYSTEM CITY: STATE: ZIP: MAINTENANCE REVIEW w ,5 vl/. �8r8 SINGLE FAMILY e PROPERTY ADDRESS: OTHER Z k� pl Lh SPECIFY: 3 SPECIFIC DIRECTIONS FOR L GATING SITE: PRIVATE WELL ti G _ L� o� � ���- COMMUNITY WELL/PUBLIC SYSTEM SYSTEM WFI# o f /B ZIv y;'ll �?- ®h ?� SYSTEM NAME l, N APPLICANT NAME r S MAILINGADDRESS 7&& i Name of Lot 2�?U ft. x U ft. W Installer a !r+ �59 Size: �� 2- acres TELEPHONE p. Y2o0 c� Name of an�� Number o SIGNATUR o � Designer H %7 Bedrooms 3 X ' y PLOT PLAN Draw a dimensional lot plan, I� including: !3 ED 0 ❑Precise local1 o test 117, holes,showing //! measured distances e c r p 5 1 $ t o property boundaries. ❑Entry road1Cj1rc driveways. 4WZp TH SERVICES k4 n, NOTE: DO NOT DRAW IN 1 SYSTEM DESIGN OFFICIAL USE ONLY. DO NOT WRITE BELOW DOUBLE LINE. SOIL LOGS-f-4�2_ p 25" c�a Ue Ua 1 san I o a rn ]�Njot 4- 1-1 u In voNw, lowm 2S- EO u a�C l►�d sad p 0-ss" ,19mv<-u . &-A ru 1rted sA d IT-W t; 6 -11 "c�,,Ncll y (ftvm 11—.5�U raj"- 1 ba-*� t,0-A Depth from Original c/ I - , Grade to Restrictive 7 �YQRG �dAa Sf ►�d� �al�g Layer or Water Table: s� • In. DESIGNER DESIGNATION SCORES MINIMUM SYSTEM REQUIREMENTS Finding Score Designer Level: X One ❑Two Soil Type Vertical Separation V>in. 0 Septic Tank Daily Capacity: )AQD Gal. Flow: GPD Slope ^' 1,r / Q Appl Infilt. Parcel Size 0--TAc. 0 Rate 0- (-.7 GPD/FT' Area 6"Z) FTC Distance to Shoreline &+-It 0 FTot­a1j InspQctor Date l0/a0/98 COMMENTS/CON ITIO S FOR APPR VAL lu ete ,Irk M - ��X 'f}}1—T 3 %S" Jr'S k •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. RLC,Water Adequacy) have been met. •Any change from th specified use of the property or any site alteration affecting the system design may invalidate this permit. •This permit expires years from the date of site review. Denial of this permit may be appealed to the Health Officer within 10 days of denial date. SITE VIEW: DES NREVIEW: Approved -jNotApproved INSTALLATON: pproved ❑Not Approved BY: DATE:�Q BY DATE: G�11/ BY: �` DATE:2.11-Qq TOP: Health Dept. Copy MIDDLE: Designer's Copy BOTTOM: Applicant's Copy DtSIGN FORM — PAGE ONE Revised February is,1998 ' A design will be reviewed when 3 conies of each of the following Items are submitted: • Completed design form that has been signed and dated % Scaled layout sketch,Including all applicable Items on checklist Scaled plot plan,Including all applicable Rams on checklist s Crosaaeotlon sketch,Including all applicable Items on checklist /t< «E -0ykg4�` Permit Number. SWG Designer's Name: /7L✓.9n�e� rir Designer's Phone#: 36 m - zs z— 34G 9 Applicant's Name: Goes 3- ,e Assessor's Parcel No.: 32/ 3 r/7 Situ v 9 z Mailing Address: OD 51ee, ke, Zhiz RIJ /533e (Twelve-Digit Number) L �e /-ri 8o Subdivision: T�of ?e —SP �Z6s'6 City State .Sr zip (Name/Division/Block/Lot) X. Treatment Device ' 0 GlendonU i il(� 19%', O Sand Filter 0 Mound L�3 Sand Lined Drainfield 0 5 &nty Dept. Health Services 0 Aerobic Unit-Make/Model: O Disinfection Unit - M o HEALTH SERVICES Drainfield Type X/ _/cssure Cl ��ock Initials" 0 Gravity nch O Gravelles Chambers Date Septic Tank/Drainfield Specifications. Laterals Number of Bedrooms 3 Scngth /Class 2do Daily Flow 6 0 eod Dimg� o Septic Tank Capacity f/y galDiameter ' m Receiving Soil Type(I-6) / Number Z Receiving Soil Appl.Rate /,Z gpdy(� Separation 9 ft Required Square Footage 30o fe Orifices Designed Square Footage 300 Total Number of Orifices y' Percent Reduction Taken O Trench/Bed Width 3 ft Diameter 3 6 in Trench/Bed Length SO ft Spacing 30 in Elevation Measurements Manifold Schedule/Class Zoo Original Drainfreld Area Slope —% Length New Slope if Altered % Diameter / 7- Depth of Excavation from YS in Original Grade (Up-slope) Preferred Manifold Configuration Used? Cl Yes to Designed Vertical Separation 36 + in Transport Pipe ZOO (Down-slope) Schedule/Class L7,� in Length 6,0 ft N Cl Optional Diameter Gravelless Chambers Required? ❑Yes o p • Pump Required? 19 Yes 0 No• Dosing and Pump Chamber Pump/Siphon Specifications Number Dose Quantity Doses/Day p gal 9 Difference in Elevation Between Pump Shutoff and Uppermost Chamber Capacity /AV0 eal Orifice: y, -3 ft Pump Controls: Timer(or) Elapse Time Meter(circle if required) If Timer: Pump On , Pump Off Uppermost Orifice is 0 Higher, ❑Lower than Pump Shutoff Capacity Q Total Pressure Head: —7 Check the following components if they drain between doses: Calculated Total Pressure Head: Laterals ❑ Manifold ❑Transport (Attach Pump Curve) DESIGN FORM - PAGE TWO Revhed Februny Ia 1996' Scaled Plot Plan Scaled Layout Sketch Cross-Section Sketch O Test hole locations O Drainfield orientation and layout Referenced depth from original grade: O Property lines O Trench/bed dimensions and critical O Septic tank lid and drainfield cover O Existing and proposed wells within distances within layout depth. 100 R of property lines O D-Box/"T'/"L"locations O Critical distance measurements to cuts, O Septic tank/pump chamber location Reference depth from original grade banks,and surface water O Observation port location and restrictive strata: O Location and orientation of curtain O Clean-out location, O Laterals,trench/bed top and bottom drain and all absorption components O Manifold placement O Curtain drain collector O Location and dimension of primary O Orifice placement O Sand augmentation system and reserve area O Lateral placement,with distances to O Buildings edge of bed Other cross-section detail: O Direction of slope indicator O Audibletvisual alarm referenced O Observation ports and clean-outs O Waterlines O Scale of drawing shown on scale bar O Roads/easements/driveways/ ( os5 set hoh rtttarm8lr(frL iUts3t�tytrtiil parking La*oatdntormattan for mnuR 'sstt nr system z' cu O Critical resource lands(if applicable) O North arrow and scale of drawing OVeYall fi[I dutletisronS , Sett[edrap deplhscgtyawaad odg#ak Q tTp slaps.dowDslDpe,altd ettdstope .. bedyy. shown on scale bar : £1 Upslopeattd Hoivasfopettlidet�Vattori Additional Information O Design staked out O Operation and Maintenance Notice Attached " 1 O Waiver(s)Attached £<L t. i� ;S11aW°�fROYI: aciF''�hs;.$0 The undersigned designer❑does, 04o'es not,waive the requirement to be notified by the installer of the installation and given 48 hours to perform a final inspection prior to cover: Signature of Designer Date 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: 641 Et#ironmental Health Spe6talist Date Caution; DESIGN APPROVAL IS VALID ONLY UNDER THE]FOLLOWING CONDITION: ✓ 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: 16,�Q�a67 ✓ The system is installed by a certified installer,unless prior authorization is obtained from Mason County Department of Health Services. ✓ Drainfield site conditions have not been altered to adversely affect conditions of design approval w r °° I w O v 4Kld � 0 \ O \I w0 A N < FO• �\+ IJ 14i•W '(n K � vl N J tXf W U O K 11 . 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SEPTIC TANK 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? -7- 11. D-Box Leveled with water and/or speed leveler(circle)? x M DRAUaZM 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? E) Gravelless chambers utilized? F) System dimensions the same as shown on the design? G) Gravel clean,properly sized,and proper depth? H) PitnsuRE Sysmis 1) Sand quality ASTM C-33? 2) Head height uniform and x24 inches? 3) Clean-outs and observation ports present? 4) Mound: Side Slope IN 5) Owner informed electrical connections must be made V by owner or licensed electrician and inspected by L&V IV. PUMP/PLMIP CHANM A) Screen basket or uent fil (circle one)installed? B) Riser installed for access? C) Alarm installed? D) Pump on timer or demand(circle)? V. As-BuiLT REQuram? VI OTHER CohoAFtTrs/OBsKRvATioNs The undersigned has reviewed this installation and verifies these findings on behalf of Mason ty Department of Health Services. 2,-O-cM Sanitarian Date C\MyFika\fi,=1diedLWpd Revised 9t26/97 AS-BUILT FORM Revised Febmaq rr PARCEL IR�NTIFIGA'TION Applicant , a �Slbe��_ Assessor's 5—Pcj —oy2 Parcel # ..._. (Twelve-Digit Number) Permit Number swe �- owY Installer Subdivision (Name DivisloNRiock ol) — — Designer INST'A L CHEGKLI57 N/A Yes Prior to Completion I. SEPTICTANK 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? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . — _4L_ - E) Dividing wall intact? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VL — F) Risers installed for access? . . . . . . . . . . G) Tank Size:1/0-0 gal.; Manufacture ku.^R II. D-Box A) Leveled with water? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . �- B) Speed leveler used? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -� -- - I III. DRAINFIELD J A) >10 ft from foundation and 3Efrom rope lines? . . . . . . . . . . . . . . . —.-- B) >100 ft from wells and surface water? . . . . . . . . . . . . . . . . . . . . . . . . . . . . C) >10 ft from potable water lines? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N/ - D) Laterals level to± I inch& end caps present if not looped? . . . . . . . . . . . -- F) Gravelless chambers utilized? . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . V --- F) System dimensions the same as shown on the design? . . . . . . . . . . . . . . . . ---- G) Gravel clean, properly sized, and proper depth? �- H) PRESSURE SYSTEMS I) Sand quality ASTM C-337 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Y 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 J owner or licensed electrician and inspected by L&I? . . . . . . . . . . . . . —— IV. PUMP/PUMP CHAJABER, A) Pump make; Pump model oSP 33 — - B) Chamber size M gal; Manufacture euw6 -tLv. C) Height of pump off bottom of Cpump chamber '-e- /i inches , - D) Pump chamber draw-down , '(145' gallons per inch B) Pump capacity x :13, .gallons per minute F) Pump controls: Timer(or) Elapsed Time Meter (circle if installed) J If timer is used: Pumv On Pump Off - G) Screen basket or(duent filter circle one) installed? . . . . . . . . . . . . . . . . H) Riser installed for access? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I ) Alarm installed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . As-BUILT DRAWING GtFckt,tSr ----- `i Dminficld & manifold nricmation & layout W1 Ticnch/bed dimensions and critical distances within layout Scil!icihemp ten.k U Location of buildings. 1D Observation port & clean- nut localion. ❑ Location of wells & roads. I 14 Undisturbed native soil hew ec ti trenches. Worth arrow I I CAUTION: Uionr adjustments to septic tank location and drainfield orientation made in the Ocld by the installer are generally acceptable to betl. and Ii:c de6g,ncr,but could in certain cases compromise the viability of the system. It is the installer's responsibility to obtain prior written approra! from either the hcalat department or the designer before making any deviations from the design that afreet the system viability. Any deviations from the appro�cd dcsir.ir..is•F: shown above. CERTIFIOATIONO:# NSTALLATION Installer Check a box from Row"A" and "B", sign and date the certification I A. d certify that I installed the system without any ❑ 1 certify that all deviations four the dcsicl: Lievintion from the design stamped "APPROWD" by "APPRovGD" by MCDI IS arc shown above \1CDIhIS B. Q I certify that I contacted the designer and left the ❑ I did not contact the designer prior to final cover hcra.Isc 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 bejust cause for immediate suspension of my installer certification. 2-I1-qq Signature of Install9fDate The undasiancd approves this installation on behalf of Mason County Department of Health Services. fop Sanitarian Datc S' Lor K I ti J _ L 7 M K 1W3S3 ,oh 1 4 9 POV