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Home My WebLink AboutSWG2019-00439 - SWG Application / Design - 11/7/2019 OFFICIAL USE ONLY MASON COUNTY PUBLIC HEALTH DATE RECEIVED: ONSITE SEWAGE SYSTEM APPLICATION AMOUR CEIVED: RECE DB: W CD PO Box 1666,415 N 6th Street,(Bldg 8) Shelton WA,98584 G m Shelton:360-427-9670 ext 400 Belfair:360-275-4467 ext 400 C` VG I Q _ Q c L( .?f Uo O Z cn Z 'G APPLICANT PHONE > > - AIcuct oW II m m MAILING ADDRESS-STREET,CITY,STATE,ZIP CODE r P6 occ SITE ADDRESS-STREET,CITY,ZIP CODE W ( 1 C 3 e.,k l\ s�, e sew SL( , m NAME OF DESIGNER PHONE �tll_ I- ______________________________________e5 yo - c, t NAME OF INSTALLER PHONE - s&- V \IOJ I.L-C, ` 6T 4.CHECK ALL APPLICABLE ITEMS DRINKING WATER SOURCE g ❑ NEW CONSTRUCTION ❑ RV HOLDING TANK ONLY VPRZATE ATE INDIVIDUAL WELL N I0' ❑ REPLACEMENT SYSTEM ❑ INSTALLATION PERMIT ONLY TWO-PARTY WELL Z ❑ TABLE 9 REPAIR ❑ SINGLE FAMILY ❑ COMMUNITY/PUBLIC WATER SYSTEM Iw I TANK(S)ONLY ❑ COMMERCIAL SYSTEM NAME: I ❑ UPGRADE TO EXISTING ❑ OTHER: BEDROOMS LOT SIZE ❑ EXISTING FAILURE "Record Drawing required for all Installations" O - 1 W DIRECTIONS TO SITE-BE SPECIFIC AND ADVISE OF ANY NEEDED INFORMATION FOR ACCESS(ex.locked gate) n jo o Io (- SITE MUST BE FLAGGED FROM MAIN ROAD AND TEST HOLES MUST BE FLAGGED WITH TEST HOLE NUMBERS OFFICIAL USE ONLY BELOW THIS LINE UPGRADE/FAILURE SOURCE(for reporting purposes) ❑VOLUNTARY ❑MAINTENANCE/PUMPING ❑BUILDING PERMIT ❑HOME SALE ❑COMPLAINT ❑OTHER: INSPECTOR SOIL LOGS COMMENTS/CONDITIONS SOIL CODES: V=VERY G=GRAVELLY S=SAND L=LOAM Si=SILT C=CLAY E=EXTREMELY R=ROOTS INSPECTOR SIGNATURE DATE APPLICATION EXPIRATION DATE APPLICATION APPROVED BY DATE THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE REVISED 3/2/2015 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG 2019-00439 Parcel# 12108-24-90094 Applicant Name John & Nanci Powell Subdivision (Name/Div/Block/Lot) Applicant Address 181 E Jack Powell LP RD City, State, Zip Grapeview, WA 98546 Installer Name Hanson Excavation LLC Site Address Same Designer Name INSTALLATION CHECKLIST ❑ Full System Installation UI Tank(s)Only ❑ Drainfield Only ❑ Repair ❑Other System Type Pretreatment Type >5ft. fromfoundation? - - - - - - - - -- - - - - - - - - - - - --- - - - ❑ N/A •YES ❑ No >50 ft. from wells? - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ❑ ■❑ ❑ >50ft.fromsurfacewater? - - - - - - - - - -- - - - - - - - - - - - - - ❑ t❑ ❑ Z Cleanoutbetweenbuildingandtank? -- - - - - - -- -- - -- - - - - - ❑ ❑■ ❑ V Tank baffles present? - - - - - - - - - - - - - - - - - - - - - - - - - - - ❑ ■❑ ❑ F- 24" access risers over each compartment?- - -- - - - - - - - -- - - - ❑ ❑■ ❑ W Effluent filter installed?- - - - - - - - - - - - - - - - - - - - - - - - - - - ❑ 0 ❑ N Septic tank size 1200 gal Manufacturer Sound Placement Services 0 D-box water level and speed levelers used? - - - - - - - - - - - - - - - ❑ N/A ❑ YES ❑ NO 0O Manifold/D-box accessible from surface? - - - - - - - - - - - - - - -- ❑ ❑ ❑ 0°Z Check valves installed? - - - - - - - - - - - - - - - - - - - - - - - - - - ❑ ❑ ❑ OQ 2 Transport Line Size Schedule/Class Bedrooms installed (check one) ❑ 2 ❑3 4 ❑ 5 ❑6 ❑Commercial/Other >10 ft.from foundation?- - - - - - - - - - - - - - - - - - - - - - - - - - ❑ N/A ❑ YES ❑ No >100ft. fromwells?-- -- - - - - - -- - - - - - - - - - - - - - - - - - - ❑ ❑ ❑ W >100ft. fromsurfacewater? - - - - - - - - -- - - - - - - - - - - -- -- ❑ ❑ ❑ >10ft.frompotablewaterlines?- - - - - - - - - - - - - - - - - - -- -- ❑ ❑ ❑ Z > 5ft. frompropertylinesandeasements?- - - - - - - - - - - - - - - - ❑ ❑ ❑ W > 30 ft. from downgradient curtain/foundation drains?- - - - - - - - -- ❑ ❑ ❑ Drainfield level and observation ports present - - - - - - - - - - - - - - ❑ ❑ ❑ ❑ Graveless chambers or ❑ Clean gravel used? (check one) Proper cover installed over drainfield?- -- - - - - - - - - - - - - - - -- ❑ ❑ ❑ Pump tank setbacks consistant with septic tank?- - - - - - - ---- -- ❑ N/A ❑t YES Pump tank size 1200 gal Manufacturer Sound Placement Services 24" access riser(s) and accessible from surface?- - -- - - - -- -- -- ❑ 0 0. Alarm or Control Panel Installed? - - - - - - - - - - - - - - - - - - - - - ❑ Q Control Panel equipped with Timer/ETM/Counter - - - - - - - - - - ❑ ■❑ o Pump installed in ❑ Bucket or ■❑ On Block or ❑ Other Q n' Pump Make/Model Little Giant/WS100H t❑ Floats or ❑ Transducer Gu CL Tank draw down in/min Pump capacity gpm Squirt Height a Pump on time 1 min Pump off time 1.5min Daily flow set at gpd Updated 8/21/2018 Mason County OSS Installation Report pg. 2 Parcel# 12108-24-90094 ABANDONMENT RECORD Were existing septic components abandoned as part of this project? -- -- -- - - - - -- - -- ■❑ YES NO If yes, please describe: Old septic tank was pumped and decommisoned when new house was built Were all components pumped out and properly abandoned per WAC246-272A-0300? --- - - - - - j■ YES ❑ NO RECORD DRAWING This is a permanent record and must be accurate and descriptive enough to re-locate in the need of maintenance activities and future development. Typical Record Drawings contain: Drainfield&manifold orientation&layout,Septic/pump tank location,North arrow,reserve drainfield,existing and proposed buildings,location of wells,waterlines, wells,observation ports,cleanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays in final installation approval and related permits. Record Drawing Attached CERTIFICATION OF INSTALLATION INSTALLER DESIGNER/ENGINEER I certify that I installed the system in accordance with 1 certify that the system has been installed in accor- the septic design stamped"APPROVED"by Mason dance with the septic design stamped"APPROVED"by County Public Health and that any deviations shown Mason County Public Health and that any deviations here have been cleared/approved by both the designer shown here have been cleared/approved by both and Mason County Public Health and meet all State myself and Mason County Public Health and meet all and Mason County Codes. State and Mason County Codes l further certify that all information contained on this I further certify that all information contained on this form and attached Record Drawing is accurate. form and attached Record Drawing is accurate. 44/'ti 4/13/2021 Signat of Installer Date Jared Hanson Printed Name of Signee MASON COUNTY PUBLIC HEALTH The undersigned approves this Installation Report and Record Drawing on behalf of Mason County Public Health: crrecvn V(41-2,f— Signature of Environm ntal Health Specialist Date (stamp, signature and date) THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 8/21/2018 .a?NDIS3.Q Q35N3OJ.l. {v�vi5 3�,OQlg�J3tIJO �Y�•. Gk ~. 1C7tl1 �.� � �•.,�jog, ��'�•m"""-1 n j - 1 Wit., 071 0 ruocn� � h c d OQ ?a.cLN "s� I / 5 c1 ?ea 111L iL 4 I'1 2 — Sgt /�, 0,10-1 111j � r ,;�;`� mod, � �, w�o� �,� ,,,� • , � ' . ,, a., ,Kl-bi.♦ rt.I �� tti . 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