HomeMy WebLinkAboutSWG93-1101 installed 10/26/1993 - SWG Application / Design / As-Built - 8/17/1993 MASON COUNTY DEPARTMENT OF HEALTH SERVICES PERMIT NO. SWG - H
N
426 W. CEDAR/P.O. BOX 1666/SHELTON, WA 98584 Date - N. a
PHONE (206) 427-9670 Receipt No. a H
Amount$ 1 Z
0
CHECK APPLICABLE ITEMS �/ <
m m
MAILING ADDRESS. DAYTIME PHONE: - INSTALLING NEW SYSTEM
E • R\ $ REPAIRING OLD SYSTEM -
CITY: STATE: ZIP; EXPANDING SYSTEM
pnpk
SINGLE FAMILY m
PROPERTY ADDRESS: OTHER Z
• D\ n W A SPECIFY: 3
SPECIFIC DIRECTIONS FOR LOCATING SITE: y $ rc m PRIVATE WELL m
CYlaSorN LK Or. Kl� Q\ � (?�a R *A it, PUBLIC SYSTEM
M+K'F-x Stn d . b /`(�n \� or VC • c� a SYSTEM ID NUMBER Ilk'
c r k. . iD th i 'to r a..r*�, SYSTEM NAME
ri Coo po {\ c- Q or, eE + . APPLICANT
S NAME Z"c t M+ h
Name of Lot =N_ft. x _ft. MAILING ADDRES y
Installer
Size: )• 6--) acres TELEPHONE b- 4 P n
Name of Number o SIGNATURE C, o �I
Designer Bedrooms I, )
PLOT PLAN Pq h P"
Draw a dimensional plot plan, y 3n
including: to
o o N
❑Precise location of test 3 1 g"yS x f
holes,showing T o qd h measured distances to M)KKeISen
property boundaries. ` n to
❑Ent road;other roads, Ilto r p driveways.
Q I�NOTE: DO NOT DRAW IN S
SYSTEM DESIGN
OFIE IAL USE ONLY. DO NOT WRITE BELOW DOUBLE LINE.
Cs SOIL LOGS
.Ing
in.2ra
Vert �/�, �1 epth from Original
V er�) �J r�i O Grade to Restrictive
J Layer or Water Table: In.
DESIGNER DESIGNATION SCORES MINIMUM SYSTEM REQUIREMENTS
Finding Score Designer Level: Vane 0 Two
Soil Type 5)
Vertical Separation in. Septic Tank Daily/�Capacity: Gal. Flow: GPD
Slope ss 7 Appl Infilt. '
Parcel Size l« Ac 4LI Rate GPD/FT2 Area � FTz
Distance to Shoreline Total ,7 Inspect � / Date
COMMENTS/CONDITIONS FOR APPROVAL
Any change from the specified use of the property or any site alteration affecting the system des!gn may invalidate this permit.
This Permit expires 3 years from date of site inspection.Denial o is permit may be appealed to the Health Offlcv-Att"'n 10 days of denial date.
SrrE: Approved Regrind ❑ DESI ved ❑Not A rov INSTA I7S Approved ❑Not Anproved
BY: DATE: BY: DATE: BY: 70( DATF10
TOP: Health Dept.Copy DLE: Designer's Copy OTTOM:Applicant's Copy
'OES,aGN ,FORM - PAGE ONE Revised 05/21/93
A design will be reviewed when 3 copies of each of the following items are submitted:
• Completed design form that has been signed and dated
• Scaled plot plan, including all applicable items on checklist
Tlayout sketch, including all applicable items on checklist
u ection sketch, including all applicable items on checklist
SEP 3 193
PARCEL IDENTIFICATION
V
Permit Number SvJ(1CA3- Designer's Name OAG T7tELF
Applicant's Name '(�no,l SM ('rl-4� �,Ay�2q MgCSo�Prop. owner's Name Sfl-Mt,
Mailing Address C- Q\ P(u)JAS).J `1 Prop. Street Address
S�eL�I�1J �.lP gCSSFS4 city sesao zsp
C 1ty Statr ZYp
Assessor' s Parcel No. 3a�3S �J ri'00� ' Subdivision
pt)
(2walva-D191t NumUar)
DESIGN PARAMETERS Date
J J J J
Designed Vertical
Separation
Mound Subsurface Pressure Gravity Bed Trench a
in
i
Septic Tank/Drainfield Specifications
No. Bedrooms .3 Pressure Distribution? Yes No
Daily Flow � .....................i (If yes, proceed. . . ) .....................
::.....................
Septic Tank Capacity l� gal
Receiving Soil Type (1-6)
Receiving Soil Appl. Rate �, 4Pd/ft2 Laterals .
Trench/-� Bottom Area y6o ft2 Schedule/class �rrct O�PF 4,,
Trench/1rd Width 3 ft Length a�0 ft
Lineal Footage - ft Diameter in
Number 3
Elevation Measurements Separation 0 ft
Orig. Drainfield Area Slope D % Orifices
Final Drainfield Area Slope D % Number/Lateral Pair
Depth of Downslope Edge of Diameter in
Trench/Bed from Orig. Grade 24 in Spacing
Manifold
Pump Required? Yes �No Schedule/Class
...................c (If yes, proceed. . . ) EE...................... Length ft
Diameter in
Pump/Siphon Specifications T sport Pipe
Difference in Elevation Between Pump Shutoff Schedule/Class ft
and Uppermost Orifice ft Length
Diameter in
Uppermost Orifice is ❑higher, lower Dosing and Pump Champer
than Pump Shutoff # Dose /Day
Capacity @ Tot. Pres. Head gpm Dose Quantity dal
Calculated Tot. Pres. Head ft Chamber Capacity oal
p (Attach Pump Curve)
S'O
DESIGN,,FORM — PAGE TWO Revised 04/21/93
DESIGN CBBCLISTS
Scaled Plot Plan Scaled Layout Sketch Cross-Section Sketch
('� Depth from original grade of
Test hole locations E Drainfield orientation following system components:
� and layout
(
u Property lines Building atubout
�]/
—y/ Trench/bed-dimensions and El
EExisting and proposed critical distances within Septic tank lid
wells, including layout
adjacent properties' ,�D- Laterals
'� Box/"T"/"L" location El Critical distance 1�/S Trench/Bed bottom
measurements to cuts, eptic tank/pump chamber
f—�/banks, surface water Vloocation
ETrench/Bed top
Location and orientation D Observation port location Drainrock depth
of curtain drain and all
absorption area [?�Cleanout location Cover depth
components 11
��/ Manifold placement Restrictive layer
Location and dimension El El
of primary system and Orifice placement Curtain drain
reserve area El Lateral placement, with D Observation ports and
81"Buildings distances to edge of bed cleanouts
-%Roads/easements Audible/visual alarm El Sand augmentation
9/Driveways/parking El North arrow Additional Mound Information
u Power/gas/waterlines '= Scale of drawing shown Upslope and downslope
on scale bar fill width
�Re,£erence point location
Additional Mound Information � Settled cap depth at
North arrow ❑ center and edge of bed
/ Endslope widthEl Scale of drawing shown Sidewall slope
on scale bar overall fill dimensions ❑
Up/downslope bed elevat.
r .
DESIGN APPROVAL [nit! Is
Date
The undersigned designer ❑does, '=�does not, waive the reqirement to be notified by the
installer of the installation and give-n/ 48 hours to perform a rfinal inspection prior to
cover.
519n�tvio ev-io-e D��19[�a D
The undersigned has revi d kap ve t is design on behalf of Mason County of Health
Services. A O _�
x� sn�n�9 en W
CAUTION: THIS DESIGN IS ONLY VALID IF STAMPED "APPROVED" BY MASON CO. DEPT. OF HEALTH
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Mason County Copt. Health Services
APPROV D
Initials
Date
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Mason County De:A. Health Serkes
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APPROVED
Initials
Date
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MASON COUNTY
DEPARTMENT of HEALTH SERVICES
Shelton,Washington 98584
(206)427-9670• Belfair:275-4467
JIRONME EALTH SONAL HEALTH �G _�3_ z WATER QUALITY
i. BO 66 3 N. FOURTH of P.O. BOX 1666
l v14, 2 r�,r1��► ��'
FIN INSPECTION v N ,b fiw P
5 - r3uL�r b
eptic System
Date: /
Time:
Installer: d ito
Applicant\Owner:
Name of Requestor: ✓
Phone # of Requestor: /1
Legal Desription:
Parcel Number: L - � - 11� -Z L
Subdivision Name: Div. Blk. Lot
Staff Initials :
FINAL INSPECTION
SEPTIC SYSTEM CHECK LIST
YES NO COMMENTS
I) SYSTEM TYPE
A) CONVENTIONAL: (T C / FIELD)
B) ALTERNATIVE: ( SUBSURFACE)
II) SEPTIC TANK
A) > Five Ft . from Foundation _
B) Foundation-Tank Line Slope:
Cleanout provided if not 1-2%
C) Baffles Intact / Clean —
D) Dividing Wall Sealed _
III) D-BOX d �
A) Water Leveled �!d- 2(J
B) Speed Levelers Used �_ _
IV) FIELD
A) > Ten Ft . from Foundation
B) > Five Ft. from Property Lines A
C) Laterals Level to ± 1 inches
D) End Caps Present If Not Looped _
E) Square Footage Adequate oL
F) Gravel Depth Adequate
G) Gravel Clean k _
H) PRESSURE SYSTEM
1) San Qualit ASTM C-33
2) MOUND. S d Slope 3 to 1 —
3) Head i > 24 inches _
4) C nouts Pr t _
5) servation Ports Present
V) POTABLE WATER LINES
A) > Ten Feet From Field r
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 l]�
COMMENTS ) fin
it J 7
1
Signature O£ anitarian Date
Revised: 10/20/92
Revised 07/12/93
A5,BtTILT FORM -PAGE ONE _
IPARCEL IDENTIFICATION
subdivision oox/zot,
Permit Number SWG9 z2lor./91
Assessor'a Parcel No. 32 )'3 S- � Z_ `'��?6
In
Name
Designer's Name
INSTALLER CHECKLIST
Yes No N/A
I. SEPTIC TANK
A) >5 ft from foundation?
B) Building stubout to septic tank: cleanout provided if not 1-2$ -- —
C) Baffles intact and clean?
D) Dividing wall intact? tJ
II. D-BOX
A) Water leveled?
B) Speed levelers used?
III. DRAINFIELD lines?
A) >10 ft from foundation and >5 ft from property —
B) Laterals level to ±1 inch?
C) End caps present if not looped?
D) System dimensions the same as shown on the design? —
E) Gravel clean, properly sized, and proper depth?
F) PRESSURE SYSTEM .
1) Sand quality ASTM C-33?
2) Head height uniform and ?24 inches?
3) Cleanouts and observation ports present? y
4) Mound: Side slope 3:11
IV. POTABLE WATER LINES
A) >loft from field or double sleeved?
B) Wells >100ft from drainfield?
V. PUMP TANK
or effluent filter (circle one) installed?
A) Screen basket
B) Riser installed for access?
C) Alarm installed?
CERTIFICATION OF INSTALLATION
"A check box from Row "B," sign and date the certification.
Faer: Check box from Row ,e
certify that I installed the system ❑ I certify that all deviations from
thout any deviation from the design the design stamped "APPROVED"this
MCDHS are
amped "APPROVED" by MCDHS. shown on the reverse aide of this form.
certify that I contacted the I did not contact the designer prior
signer and left the system open for
to final cover because the designer
spection up to 48 hrs prior to cover. waived the notification requirement.
r certify that all information contained on this form is accurate. I understand
the information contained herein is not accurate, there will be just cause for
te suspension of my installer certification.
9ersigned approves this inst of behalf ofMasonnCounnty Deepartment of Health
s.
n aCa
Health iza, -C ciY
..w...,.. ..�...,.-�....—».�-- Revised 07/12/93
AS-$ilJILT FORM' : PAGE TWO
PARCEL IDENTIFICATION
Permit Number SWG9 - Subdivision
(Nsme/D ivislo[i/8loolc/Lot)
Installer's Name Assessor's Parcel No. (TWa1v-_Di91- Numbs=)
Designer's Name
AS-BUILT DRAWING
cAUTloy: 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 aystem. It is the in-
staller's 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
11 7Dralinfield orientation ❑ Observation port location Undisturbed native soil
between trenches
ut Cleanout location ❑
bed dimensions and
North arrow
al distances within ❑ Manifold placement ❑ Scale of drawing shown
❑ Orifice placement on scale bar
"T"/"L" location Lateral placement, with Additional Mound Information
tank/pump chamber distances to edge of bed Endslope width
on ❑ Location of wells, roads on of buildings Overall fill dimensions