HomeMy WebLinkAboutSWG93-1062 - SWG Application / Design / As-Built - 8/10/1993 MASON COUNTY DEPARTMENT OF HEALTH SERVICES PERMIT NO. _ C y
SITE EV ATI N AND INSTALLATION F
Date Date <. y
426 W. CEDAR/P.(�. BOX 1666/SHELTON, WA 98584 H o
PHONE (206) 427-9670 Receipt IVA Receipt No.
Amount$ Amount$ Z F
m �
S CHECK APPLICABLE ITEMS ✓ 3 m
MAILING ADDRESS: DAYTIME PHONE: INSTALLING NEW SYSTEM I/ 0
_ O REPAIRING OLD SYSTEM 9.
CITY: STATE: ZIP: EXPANDING SYSTEM W
W p2 SINGLE FAMILY
PROPERU A DRES ' 1 OTHER Z
�j6o— 4DOO l Yw15p R1 b"n SPECIFY: 3
SPECIFIC DIRECTIONS FOR LOCATING SITE: Fr M $AEcTO rJ N. on IIW4 3 fur
PRIVATE WELL ✓ m
y =' :�cs L O - PUBLIC SYSTEM
SYSTEM ID NUMBER I W
On \ o �o o 4 SYSTEM NAME
Pu0
� 11 APPLICANT
Coi '�mcner 6 L 00 I r ^ �Q�'Kp. NAME (—
Name of Lot 172- ft. x 3140 ft. MAILING ADDRESS
Installer �� 1-14-1 imd _ gggt W
Size: 1 • 3J5 acres TELEPHONE
- q
Name of `, ICT1
Designer Number
o 2 SIGNATURE j
Bedrooms 3 X
PLOT PLAN p ys r I N
Draw a dimensional plot plan, yy L\ tt r I IW
including: Fa z"1 Y �c+�e I m
VV V o I ry
/as% h/�ia.1❑Precise location of test 0I // 3
holes,showing rl d �,,, t k yi.✓ R IO
measured distances to t
property boundaries. ` // /
Is,
❑Entry road;other roads, she
driv
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NO IJ
YSTEM DESIGN
AUG 10 I
QFEM ' ONLY. DO NOT WRITE BELOW DOUBLE INE`.
r. I ` � . SOIL O�(G?S��
v�.fo• S.9 3?•-qq rt..s.n SA-wD p(s � 39a P'!S � 7-4u
IE�•S�ti 7iu ��J-! ` -0 vL
Depth from Original If
Grade to Restrictive
Z�
Layer or Water Table: 3 ° In.
DESIGNER DESIGNATION SCORES UM SYSTEM EOUIREMENTS
Finding Score Designer Level: a ❑Two
Soil Type �
Vertical Separation r 3 Septic Tank Daily �!
�� Capacity: ' Gal. Flow: isv GPD
Slope Appl. // Infilt.
Parcel Size (•3rAz Rate oub GPD/FT' Area FT-
Distance to Shoreline -er— Total Inspector rrnn Date
COMMENTS/CONDITIONS FOR APPROVAL_//
T'4 s- e&4ra or slid 1
Any change from the specified use of the property or any site alteration affecting the system design may invalidate this permit.
This Pe4 pires 3 years from date of site Inspection.De 'al of this permit may be appealed to the Health Officer within 10 days of denial date.
SITE: ign Required ❑N ed DESIGN Approved ❑Not A proved INSTAL Approved ❑Not Approved
BY: DATE: 1j BY: DATE' -#1 BY: DATE&e-f,7
TOP: Health Dept. Copy MIDDLE: Designer's Copy BOTTOM: Applicant's Copy
ESIGN. FORM - PAGE ONE Revised 05/21/93
B design willn 3 copies of each of the following items are submitted:
S 1 tesign form that has been signed and dated
plan, including all applicable items on checklist
•O edlayout sketch, including all applicable items on checklist -
C '
=' Nois-section sketch, including all applicable items on checklist
PARCEL IDENTIFICATION
Permit Number ��w) ('- 9 Designer's Name
Applicant' s Name <.S h i�/ Aa. J /)i Prop. Owner's Name
Mailing Address /�./ y/ ip»,- 3<5 n42.,J S: �✓ Prop. Street Address /ace j
L41 l55% "L
CS�Y 5<�<o ZiH D1<Y Scsc� 21p
Assessor's Parcel No. 31 / 3 �- 2,3 % Subdivision 1.
(2va1v�-D1p1< Numbaa) (Nsm�/➢ 'LK /H1och/Lee)
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DESIGN PARAMETERS fl ak__
r t Designed vertical
LLII UUUUUU LLL''�I ILL__JJI LLJJ Separation
Mound Subsurface Pressure Gravity Bed Trench in
Septic Tank/Drainfield Specifications ,I—v�,/
No. Bedrooms 3 Pressure Distribution? Yes u No
Daily Flow 'Z%r gpd ....................EE (If yes, proceed. . . ) Ec....................::.................... ....................::
Septic Tank Capacity J gal
Receiving Soil Type (1-6) I
Receiving Soil Appl. Rate L,, & gpd/ft2 Laterals
Trench/Bed Bottom Area 16,0 ft2 Schedule/Class "
Trench/Bed Width _eft Length ft
Lineal Footage - mop ft Diameter in
Number
Elevation Measurements Separation ft
Orig. Drainfield Area Slope %8 Orifices
Final Drainfield Area Slope % Number/Lateral Pair
Depth of Downslope Edge of Diameter in
Trench/Bed from Orig. Grade / 2 in Spacing
Manifold
Pump Required? 11 Yes a No Schedule/Class
( yes, proceed. . . ) Length ft
................. . ..........................
..........................
Diameter in
Pump/Siphon Specifications Transport Pipe
Difference in Elevation Between Pump Shutoff Schedule/Class
and Uppermost Orifice ft Length ft
Diameter in
Jppermost Orifice is ❑higher, lower Dosing and Pump champer
:han Pump Shutoff # Doses/Day
'apacity @ Tot. Pres. Head gpm Dose Quantity gal
'alculated Tot. Pres. Head ft Chamber Capacity gal
(Attach Pump Curve)
S
CESICN- FORM — PAGE TWO Revised 04/21/93
DESIGN CBECKLISTS
Scaled Plot Plan Scaled Layout Sketch Cross-Section Sketch
Depth from original grade of
Test hole locations grainfield orientation following system components:
/ and layout
Property lines �ry El Building stubout
I—,,{'/ LJ Trench/bed dimensions and
u Existing and proposed critical distances within ET/Septic tank lid
wells, including layout
7acent properties' Laterals
D-Box/"T"/"L" location
r,itical distance rench/Bed bottom
measurements to cuts, Septic tank/pump chamber
Loanks, surface water location Trench/Bed top
Location and orientation Observation port location D ainrock depth
of curtain drain and all
u location LLLJJJ over depth
absorption area Cleano t � P
components ❑
Manifold placement Restrictive layer
Location and dimension
of primary system and Orifice placement Curtain drain
Feserve area
u_✓,/ El Lateralplacement, with Observation ports and
uildings distances to edge of bed cleanouts
�
Roads/easements Audible/visual alarm Sand augmentation
�2�riveways/parking North arrow Additional Mound Information
ower/gas/waterlines Scale of drawing shown ❑ Upslope and downslope
on scale bar fill width
Reference point location
I�.�/ Additional Mound Information Settled cap depth at
u/North arrow El
center and edge of bed
E�( Endslope width
Scale of drawing shown Sidewall slope
on scale bar Overall fill dimensions � qq '"��Up/dCDR g Bg bed elevat.
n.
O ecuisas
DESIGN APPROVAL S�
Date
FT
The undersigned designer does, does not, waive the reqirement to be notified by the
installer of the installation and given 48 hour to erform a final inspection prior to
cover.
The undersigned has reviewed and appr v his design on behalf of Mason County of Health
Services. i
CAUTION: THIS DESIGN IS ONLY VALID IF STAMPED "APPROVED" BY MASON CO. DEPT. OF HEALTH
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MASON COUNTY
DEPARTMENT of HEALTH SERVICES i d J
Sheltpn.Washington 98584
(2061427-9670 • Belfair.275-4467
VIRONMENTAL HEALTH PERSONAL HEALTH WATER QUALITY
). BOX 1666 303 N. FOURTH P.O. BOX 1666
FINAL INSPECTION
Septic System
Date:
Time: �• O�
If
Installer: A ,
Applicant\Owner: lAll tLw
Name of Requestor: ��
Phone # of Requestor: 3 `M-7 /L1g0 -0190
Legal Desription:
� t
Parcel Number:
Subdivision Name: Div. Blk. Lot_
Staff Initials :
FINAL INSPECTION '
SEPTIC SYSTEM CHECK LIST •
I) SYSTEM TYPE YES NO COMMENTS
A) CONVENTIONAL: TREN / FIELD)
B) ALTERNATIVE: (MOUND/SUBSURFACE)
II) SEPTIC TANK
A) > Five Ft. from Foundation
B) Foundation-Tank Line Slope :
Cleanout provided if not 1-20s )(
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 SY
1) Sand Qua ' ty AS C-33 _
2) MOUND: San e 3 to 1 _
3) Head Hei > 2 c_hes _
4) Clea is Present _
5) Ob zvation Ports Present _
V) POTABLE WATER LINES
A) > Ten Feet From Field
Components or Sleeved _
B) WELL > 100 Ft. from Field ti
VI) PUMP TANK
alle
A) Screen _
1) Basket uent Filter _
B) Riser r Access �t _
C) Al Installed _
VII) AS BUILT REQUIRED
COMMENTS
-Z �(3
Signature Of Sanitarian Date
Revised: 10/20/92
AS-BUILT FORM - PAGE ONE Rwised 07/12/93
PARCEL IDENTIFICATION
Permit Number SWG9 j - /0 6 `.Z Subdivision
(Naaa/p ivisior/alo ole/Lot)
Installer's Name ��./' ��/y�,=.2 - C�"/�� Assessor's Parcel No. 3 21352 '3 Z c0/y
Designer's Name jga �
INSTALLER CHECKLIST
I. SEPTIC TANK Yes No N/A
A) >5 ft from foundation? ✓ _
B) Building stubout to septic tank: cleanout provided if not 1-2% V
C) Baffles intact and clean? - —
D) Dividing wall intact?
II. D-BOX
A) Water leveled?
B) Speed levelers used?
III. DRAINFIELD
A) >10 ft from foundation and >5 ft from property lines?
B) Laterals level to tl 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? _
4) Mound: Side slope 3:1? -
IV. POTABLE WATER LINES
A) >10ft from field or double sleeved?
B) Wells >100ft from drainfield? _
V. PUMP TANK
A) Screen basket or effluent filter (circle one) installed?
H) Riser installed for access? _✓
C) Alarm installed? _
CERTIFICATION OF INSTALLATION
Instal r• Check box from Row "A," check box from Row "B," sign and date the certification.
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. Zcertify 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 i urate, there will be just cause for
immediate suspension of my in aller if'
61g sllar Para
The undersigned approves this i etal 'on of behalf of Mason County Department of Health
Services.
Health I[.apaotor Para
A$-BUILT FORM - PAGE TWO Revised 07/12/93
PARCEL IDENTIFICATION
Permit Number SNG9 1 6 2 Subdivision
(Nsma/D1v1a1or�/BlOcle/Lot)
1 I r
Installer's Name /�, CO Assessor's Parcel No.
Designer's Name sai,. cswa lva—D1g1C K,,...Daz)
AS-BUILT DRAWING
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'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-BUILT CHECKLIST
Drainfield orientation Observation port location Er Undisturbed native soil
and layout/ between trenches
�' Cleanout location
Trench/bed dimensions and El Manifold
arrow
critical distances within Manifold placement ❑
ayout ❑ Scale of drawing shown
O fice placement on scale bar
Box/"T"/"L" location
La eral placement, with Additional Mound Information
Septic tank/pump chamber stances to edge of bed ❑
location Endslope width
Location of wells, roads
Location of buildings 1:1 Overall fill dimensions