HomeMy WebLinkAboutSWG Application - 9/10/2013 f
., WAGF SYS'i c0 PERMIT APPLICATION ,�0-d3—� NO erm t' Xplr'es
FOR ONLY
MASON COUNTY HEAL I H DEPARTMENT DATE BASIS FOR FEE AMOUNT RECEIPT NO:
ENVIRONMENTAL HEALTH SECTION c
303 NORTH 4th STREET • SHELTON, WA 98584
PHONE (206) 426-5561
A RESS
��^i`•�• �Lam✓ . —PHONE
�D BmX LL7L Qj ;� di 72f i q SITE: Approved ❑ Not Approved
PROPS�'y\Ty� OWNER
V� '� PHONE B
ADDRESS
D SIGN SYSTE SQUIRED
SEWAGE SEWAGE
CONTRACTOR%7kug��' �,� DESIGNER rn.2— INSTALLATION: ❑ Approved ❑ Not Approved;.
LEGAL DESCRIP�TIJOee.N a� Cl/ �,1 BY
S
DEPTH TO WATER TABLE
TYPE OFOlj{L��L+� NO. OF LOT
BUILDING � 'L -BEDROOMS- -X SOIL TYPE0"^ ' � 4
n6 .
SINGLE RESIDENCE PUBLIC WATER NAME 'j,� )
WATER SYSTEM SYSTEM n
COMMERCIAL ONLY iC(y� �v�'{ 4 M' ✓ 7'
LIQUID WASTE G.P.D. � r. uey,
I
DIRECTIONS TO SITE:
�Qc-Ae 01 �EPTICTANK(S) GAL. PUMPREO.
DISTRIBUTION TILE TOTALth`7� FEEjk
,"T. 1. FINAL INSPECTION REQUIRED IIEFORE BA KFILLINGf
DEPTH OF x.t,
BACKFILL. '
�
T,STRAW OR PAPER '3y
'¢
STONE�� 1Txs'
OVER TILE
E�PIPE SIZE. ..
[O 6rWVW ;
04DFR TILE
SITE PLAN AND SPECIAL STIPULATIONS
„a
(INDICATE DIRECTION OF DRAINAGE) tR055 SECf1ONOF TREN1
OFFICE COPY
ENVIRONMENTAL HEALTH SECTION/SITE INSPECTION CHECK LIST N0. K 6 k
Check every acceptable feature. Leave every.questionable or unacceptable feature blank.
Explain every blank in the space for remarks.
ITEM APPLICABLE REGULATIONS
1) Soil in holes-describe layers & depth Art
-J -2) Existing sewage systems . VI Sec. 3.5 (a), VII 3.3, 3.7, 10.2
_' 3) Existing structures-check use
-4) Existing wells-check construction VI 3.5 VII 4.1, 4.2
5) Presence of fill VI 2.1 (b) VII 4.1
_b) Has soil been removed VI 1.8 VII 3.6
VI 2.1 (c), 2.4, 3.5 (f),
f 7) Salt water VII 4.1
8) Lake
9) River
�0) Creek
11) Stream
12) Pond
-13) Swamp
14) Misc. surface water
_% Property VI 3.5 (f) VII 4.1
C16) Banks or cuts VI 3.5 VII 4.1, 3.7
17) Distance to public sewer VI 3.5 (g), 9.2, 10.2, 10.3 &
18) Water table-record depth 10.4
_��19) Slopes VI 3.5 (d) VII 1.4
/; 20) Driveways and roads VI 3.5 (e) VII 3.7, 4.1
21) Drainage patterns VII 4.2
��22) Interceptor drains VI 3.5 (e) VII 4.1
=23) Culverts VII 3.8
_/ 24) Water lines VII .6, 4.1
25) Flood control zones
,7 2
VII .4
26) Roof drains VII 3.2
�27) Vegetation VII 3.2
REMARKS:
P/ffffff N
4a
/0 p
DATE �6 PITY
V I
MASON COUNTY
DEPARTMENT of GENERAL SERVICES
Courthouse Annex 2 N. Fourth & W. Cedar
P.O. Box 186 Shelton, Washington 98584
(206) 426-5593
building environmental health maintenance parks&recreation planning sewer&water
July 25, 1985
P-0 _ rn�12�2.
Re: Septic Tank and Drainfjield Installation
We have not received a record of final "as—built" regarding the
installation of your septic tank and drainfield.
We encourage you to finish all the paperwork regarding these
records. Mortgage companies and lending institutions are
constantly contacting our office so that we may verify a
legal system. Your system is not considered legal until an
approved "as—built" is on file in our office.
We have enclosed the appropriate form for your convenience.
Please fill out as much information as possible and sign
the form as "Certified" installer. Return all copied to our
office, we will complete the process and mail your file copies
to you.
Thank you for your attention to this matter.
Sincerely,
ENVIRONMENTAL HEALTH DIVISION
P. 0. Box 186
Shelton, WA 98584
426-5561
Xa3 to- 76- 0035O
I
V � y
f\
a
I
� a
M
3
� � r
>9 , Oti
� 3
3 J A I� 0.� R)
O �3 ° I I mm oti
Cl
ti o
d °
QIQ a � d
S r , i' o
Q Y O 110
�� ,Q �.� moo• t