HomeMy WebLinkAboutSWG2022-00317 - SWG Application / Design - 6/3/2022 f4 tN 415 N 6TH STREET,SHELTON,WA 98584
MASON COUNTY SHELTON:360-427-9670,EXT 400
(41 COMMUNITY SERVICES BELFAIR:360-275-4467,EXT 400
, ELMA:360-482-5269,EXT 400
/ Bo,ldng,Plonning,Environmentai Health,Community Health
FAX:360-427-7787
On-Site Sewage System Tank Only Permit: SWG2022-00317
OWNER JONES THOMAS W& CHRISTIE Phone:
KALOPER
Address: 3930 HOYT AVE EVERETT, WA 98201
APPLICANT JONES THOMAS W& CHRISTIE Phone:
KALOPER
Address: 3930 HOYT AVE EVERETT, WA 98201
SEPTIC DESIGNER MIKE JERKOVICH-Harborstone Phone: 253-514-0958
Consulting LLC
Address: PO BOX 296 GIG HARBOR, WA 98335
Site Address: 6400 NE NORTH SHORE RD
Primary Parcel Number: 222095400082
Permit Description: Garage tanks (septic & pump)for SWG2020-00014
Permit Submitted Date: 06/03/2022
Permit Issued Date: 07/11/2022
Issued By: Luke Cencula
Current Permit Fees Paid: $240.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 07/11/2023 (based on date of inspection)
Type of Work OSS New Construction
Components being Replaced: Septic and Pump Tanks
Surfacing Sewage? No Existing Failure? No
Shoreline? No Horizontal Setbacks Met? Yes
Number of Bedrooms: 0 Drinking Water Source: Public Water System
Additional Details: Septic and pump tanks
Permit Conditions:
4 Proposed development subject to zoning requirements and approval by the planning
department staff per Mason County Title 17.
2 Permit must be installed by a Mason County Certified Installer unless prior written
authorization from Mason County is obtained.
3 Mason County Asbuilt Form, Record Drawing, and Installation fee must be submitted for
final installation approval.
1 Horizontal setbacks per WAC246-272A-0210 must be maintained, unless prior approval is
obtained
THIS PERMIT MUST BE ONSITE DURING INSTALLATION OF OSS.
PROPERTY OWNERS ARE RESPONSIBLE FOR DETERMINING AND MARKING ALL PROPERTY LINE AND EASEMENT LOCATIONS.
THIS PERMIT MAY BE REVOKED IF THE SITE CONDITIONS HAVE CHANGED SINCE THE SITE WAS INSPECTED AND/OR DESIGN
APPROVED.
FINAL INSTALLATION APPROVAL IS REQUIRED PRIOR TO TEMPORARY OR FINAL OCCUPANCY OF ANY RELATED STRUCTURES.
For Final Inspection visit: www.co.mason.wa.us/health/environmental/onsiteloss-inspection-request.php or call:
360-427-9670, extension 400.
OFFICIAL USE ONLY
DATE RECEIVED:
MASON COUNTY cn
11 x' COMMUNITY SERVICES AMOUNT RECEIVED: RECEIVED BY:
v CO
CD
Public Health(Community Health/Environmental Health) C (n
360-427-9670,ext.400 or 360-275-4467,ext.400 /' /�
415 N.6th Street-Shelton,WA 98584 SWG �-1-y - 003t1
Z rn
ON-SITE SEWAGE TANK ONLY APPLICATION
E
m n
APPLICANT PHONE m
Thomas Jones/Christie Kaloper z
c
MAILING ADDRESS-STREET,CITY,STATE,ZIP CODE
3930 Hoyt Ave, Everett, WA 98201
SITE ADDRESS-STREET,CITY,ZIP CODE
6421 NE# North Shore Rd, Belfair, WA 98528
NAME OF DESIGNER PHONE I
Mike Jerkovich 253-514-0958 \V
NAME OF INSTALLER PHONE 0 IN
TBD N Id
TYPE OF WORK(select one) DRINKING WATER SOURCE
® NEW CONSTRUCTION/UPGRADES 0 REPAIR/REPLACEMENT 0 PRIVATE INDIVIDUAL WELL 0 PRIVATE TWO-PARTY WELL Z
COMPONENT(S)TO BE REPLACED/INSTALLED 0 PUBLIC WATER SYSTEM
® SEPTIC TANK ® PUMP TANK ❑RV HOLDING TANK BEDROOMS / i .i0„„droLOT SIZE I O
ElOTHER 0.92 acres co �
OTHER DETAILS(select all that apply) TANK(S)SETBACK CHECKLIST
O t
❑ SURFACING SEWAGE 0 EXISTING FAILURE 0 SHORELINE U 100FT+PUBLIC/COMMUNITY WELLS 0 (O
SUBMITTALS 0 50FT+PRIVATE WELLS,SURFACE WATERS,STREAMS,RIVERS
® PLOT PLAN(REQUIRED) ®TANK CROSS SECTION(REQUIRED) 0 10FT+DRINKING WATER SUPPLY LINES I^,
® PUMP DETAILS(IF APPLICABLE) 0 WAIVER(S)(IF APPLICABLE) ❑ 5FT+PROPERTY/EASEMENT LINES,FOUNDATIONS,FOOTINGS v
PLOT PLAN CHECKLIST O IV
® PROPERTY LINES AND EASEMENTS ® EXISTING!PROPOSED STRUCTURES ®EXISTING/PROPOSED OSS COMPONENTS AND LINES
❑ WELLS WITHIN 100FT ® WATER SUPPLY LINES ® DRIVEWAYS/PARKING ®SURFACE WATERS,STREAMS,RIVERS,ETC...
® DIRECTION OF SLOPE/CONTOURS 0 PERIMETER/CURTAIN DRAINS ® NORTH ARROW ®SCALE BAR k\I
DIRECTIONS TO SITE AND SITE CONDITIONS:(ex.locked gate)
Left onto NE Old Belfair Hwy; 1st left onto NE SR 300/WA-300; WA-300 becomes NE North
Shore Rd; follow to 6421 NE North Shore Rd.
No gates; property is on both sides of the road; test holes are on the parcel on the north
side of the road.
OFFICIAL USE ONLY BELOW THIS LINE
UPGRADE I FAILURE SOURCE(for reporting purposes)
0 VOLUNTARY 0 MAINTENANCE/PUMPING 0 BUILDING PERMIT ❑HOME SALE ['COMPLAINT 0 OTHER:
COMMENTS/CONDITIONS
�V•Vtot.e.A° te, 5
SEWAGE TANKS MUST BE LISTED UNDER DOH"LIST OF REGISTERED SEWAGE TANKS".TANKS MUST MEET CURRENT MINIMUM SIZE REQUIREMENTS,EQUIPPED WITH RISERS
AND LIDS TO SURFACE,AND INCLUDE AN EFFLUENT FILTER(IF APPLICABLE). RECORD DRAWING AND INSTALLATION REPORT REQUIRED FOR FINAL APPROVAL.
INSPECTOR SIGNATURE DATE APPLICATION EXPIRATION DATE APPLICATION APPROVED/ISSUED BY DATE
43": / ',.1 1 O° l 1\ley).
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VI ON THE MASON COUNTY WEBSIT REVISED 12F/2015
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