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HomeMy WebLinkAboutSWG2021-00446 TANK ONLY - SWG Application / Design / As-Built - 7/27/2021 415 N 6TH STREET,SHELTON,WA 98584 F.' . ., MASON COUNTY SHELTON:360-427-9670,EXT 400 COMMUNITY SERVICES BELFAIR:360-275-4467,EXT 400 ELMA:360-482-5269,EXT 400 i / Building,Plammny,Environmental nealth,Community Heoltlr FAX:360-427-7787 On-Site Sewage System Tank Only Permit: SWG2021-00446 SEPTIC INSTALLER JOE HOUSE- House Bros Construction Phone: 360-495-4156 Address: PO Box 1820 MCCLEARY, WA 98557 APPLICANT SEMANKO GERTRUDE D Phone: Address: 1180 E SHELTON SPRINGS RD SHELTON, WA 98584 OWNER SEMANKO GERTRUDE D Phone: Address: 1180 E SHELTON SPRINGS RD SHELTON, WA 98584 Site Address: 1180 E SHELTON SPRINGS RD Primary Parcel Number: 420122100020 Permit Description: Septic Tank replacement Permit Submitted Date: 07/27/2021 Permit Issued Date: 07/29/2021 Issued By: Rhonda Thompson Current Permit Fees Paid: $230.00 (additional fees may be required upon installation of system). Permit Expiration Date: 07/29/2022 (based on date of inspection) Type of Work OSS Repair Components being Replaced: Septic Tank Only Surfacing Sewage? No Existing Failure? Yes Shoreline? No Horizontal Setbacks Met? Yes Number of Bedrooms: 3 Drinking Water Source: Private Well/Spring Additional Details: House Bros 1250 ST Permit Conditions: 3 Mason County Asbuilt Form, Record Drawing, and Installation fee must be submitted for final installation approval. 2 Permit must be installed by a Mason County Certified Installer unless prior written authorization from Mason County is obtained. 4 Proposed development subject to zoning requirements and approval by the planning department staff per Mason County Title 17. 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/onsite/oss-inspection-request.php or call: 360-427-9670, extension 400. - OFFICIAL USE ONLY MASON COUNTY — -� cn D C fn COMMUNITY SERVICES AMOUNT RECEIVED RECEIVED BY �� � v m Public Health(Community Health/Environmental Health) 0,360-427-9670,ext.402 or 360-275a467,Cot 400 S W 415 N 6th Street-Shelton DATE RECEIVED: WA 98584 _ ( yX �,/J - O O xi i Q\Jv 6 Z di ON-SITE SEWAGE TANK ONLY APPLICATION 3 APPLICANT PHONE 111r Scott Semanko 360-402-5769 z MAILING ADDRESS-STREET.CITY,STATE,ZIP CODE 3 to 14651 N. US Hwy 101 m SITE ADDRESS-STREET,CITY,ZIP CODE 1180 E. Shelton Springs Rd. Shelton, WA 98584 I Z. NAME OF DESIGNER PHONE PHONE ID) NAME OF INSTALLER < 10 /-/Cuss /3/. We,-s 3 6e y9 S V(S lc Z TYPE OF WORK(select one) DRINKING WATER SOURCE 0 ❑ NEW CONSTRUCTION/UPGRADES © REPAIR/REPLACEMENT Iii PRIVATE INDIVIDUAL WELL 0 PRIVATE TWO-PARTY WELL Z 'SD COMPONENT(S)TO BE REPLACED/INSTALLED 0 PUBLIC WATER SYSTEM 1 Iii SEPTIC TANK 0 PUMP TANK 0 RV HOLDING TANK BEDROOMS LOT SIZE IQ, ❑ OTHER 3 .75 acre ca TANK(S)SETBACK CHECKLIST I r`-' r OTHER DETAILS(select all that apply) 0 n I ❑ SURFACING SEWAGE II EXISTING FAILURE 0 SHORELINE It 100FT+PUBLIC/COMMUNITY WELLS ID III PRIVATE WELLS,SURFACE WATERS,STREAMS,RIVERS SUBMITTALS ❑ PLOT PLAN(REQUIRED) 0 TANK CROSS SECTION(REQUIRED) al 10FT+DRINKING WATER SUPPLY LINES 10 ❑ PUMP DETAILS(IF APPLICABLE) 0 WAIVER(S)(IF APPLICABLE) II 5FT+PROPERTY/EASEMENT LINES,FOUNDATIONS,FOOTINGS PLOT PLAN CHECKLIST IQ ® PROPERTY LINES AND EASEMENTS ® EXISTING/PROPOSED STRUCTURES III EXISTING/PROPOSED OSS COMPONENTS AND LINES • O WELLS WITHIN 100FT IN WATER SUPPLY LINES ® DRIVEWAYS/PARKING 0 SURFACE WATERS,STREAMS,RIVERS,ETC... al DIRECTION OF SLOPE/CONTOURS 0 PERIMETER/CURTAIN DRAINS ID NORTH ARROW ❑ SCALE BAR2 DIRECTIONS TO SITE AND SITE CONDITIONS:(ex.locked gate) ,t- eO E. (c e /4 ,_9i/'49 S A (Co r il c/e/1cr, ,/,r/ .5 fcl, mot, vxcf Ae-a1,,GI,'al� s OFFICIAL USE ONLY BELOW THIS LINE UPGRADE/FAILURE SOU E(for reporting purposes) O VOLUNTARY MAINTENANCE/PUMPING ❑BUILDING PERMIT ['HOME SALE ['COMPLAINT ❑OTHER: COMMENTS I CONDITIONS feFAC(-CCL CtqA C AC/0\- 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 7 1/1, VA1\ cS41 1 01IzI THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE REVISED 12/7/2015 \ . . • a .a= in � r tl 4 N i Y • y • N e V y .' • - Y ! 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' 1.•• . t) Ll 11 J y;. 1 ,.4 aa» _l. �a ' _f, :tsvana i as �% 4 It ; a j ^ j� C y ' •: J Cir N e •1 J a 1 7 i; 1 A Q\ • fie, .+'� e „ Y a a= 4 f d I' ; I a . 1 a } x a K , • 6.,.....a..eon-as_sac....=aa..a P......e.: DATE' 6122111 fn•llarnse:I:uY_•Kf•Jx Pr.erns:14Eo�-.t:FOR mOotci EK ENGINEERING INC. DRAFTED BY. 1250 S & 1250 S—T P.O.BOX 3097 BATTLE GROUND.WA 98604 D.R.N. ASCAQE CONCRETE PRODUCTS CO..INC PHONE: (360) 687.7668 FAX (360) 687-7669 y r;' gX? i : a 7 a x ' T V . . . . i i- . • .•-.;::.c RI,ii s�� 8 . s, .` 9liu<' L { \ i i 2. i c.- I jjjjj 1 i _� t. ter--- l 3 a It vt 1 • • �ii 1 1 g - \ ! r t -yr • L ff t I I I --__---_-ter-`c-'L- r, v- G/N/,��,-k SOr DATE: •Eraisr crt.rxnL-. 612211 i �;•.•, EK ENGINEERING INC. DRAFTED BY. 1250 S & 1250 S T P.O BOX 3097 BATTLE GROUND.WA 98604 DRN.SCALE NTS CASCAUE CONCRETE PRODUCTS CO.INC PHONE: (360) 687-7668 FAX. (360) 687-7669 ye,,, e/"fy ///1 e APPROVED 3d JUL 2 9 2021 MASON COUNTY ENVIRONMENTAL HEALTH RET Prose? lavt D 1-1kKoc °18„,,Ae/ � X • • "(1.elal( " n - I xi" C e I d EyiS7it'G 5 e 70.--al 1. JUL 2 9 2021 k� a .c\ ON COUNTY ENVIRONMENTAL HEALTH esot4ibREt - P rah 6; ' E H , c,iseA Mason 'County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH —T — APPLICANT! PERMIT INFORMATION Permit Number SWG Z - Parcel Z. '6607� Applicant Name V Subdivision (Name/Div/Block/Lot) Applicant Address E r s Rd. City, State, Zip ��t Q n t Installer Name Se 0 1'S Site Address "U) Designer Name INSTALLATION CHECKLIST ❑ Full System Installation a Tank(s)Only ❑ Drainfield Only ❑ Repair ❑Other System Type Pretreatment Type - ❑ N/A YES ❑ NO >5 ft. from foundation? - El ❑ >50 ft. from wells? ❑ lip • >50 ft. from surface water? ❑ 0 ❑ FQ- Cleanout between building and tank? El ,I, ❑ U Tank baffles present? ❑ a ❑24" access risers over each ccmpartment?- Ela rAl ❑ � Effluent filter installed?- � r� � Septic tank capacity (working) IZ _gal Manufacturer f� !I ❑ N/A El YES ❑ NO D-box water level and speed levelers used? - - El ElDO Man - d/D-box accessible fro surface? ❑ ❑ • m2 Check val - installed? - - - 64 Schedule/Class 2 Transport Line Siz mercial/Other Bedrooms installed (check ••.) ❑ 2 '12 3 ❑4 ❑ 5 ID6 CI N!A ❑ YES ❑ NO >10 ft. from foundation?- - - - ❑ ❑ El O >100 ft.from wells? - - - - ❑ ❑ ❑ W >100 ft. from surface water? El El El >10 ft. from potable water linen? ❑ ❑ CI > 5 ft. from property lines and easements? ❑ CL > 30 ft. from downgradient cu`tain/foundation drain . - - El ElCI• Drainfield level and observati'�n ports present - - - ❑ ❑ ❑ Graveless chambers or ❑ Clean ! avel used? (check one) , El El Proper cover installed over diainfiel• . - Pump tank setbacks consist-, with septic tank? - - ❑ N/A ❑ YES ❑ NO • Pump tank capacity (fl..d)__gal Manufacturer . 0 Z ❑ • 24" access risers .nd accessible from surface? El ❑ 1-- Alarm or Cont • Panel Installed? - - ❑ ❑ LI Control P el equipped with imer/ ETM/ Counter- ID Other n- PumpAtalled'stalled in ❑ Bucket or ❑ On Block or ❑ Transduce :' d ❑ Floats or Pump Make/Model it a Tank draw down in/min Pump capacity_____gpm Squirt Height Pump off time Daily flow set at gpd Pump on time U ted 8/21n0t8 # Mason County OSS Installation Report pg. 2 Parcel �i ABANDONMENT RECORD - ❑ YES II NO Were existing septic components aba doned as part of this project? If yes, please describe: ❑ YES 1� NO Were all components pumped out and 4 roperly abandoned per WAC246-272A-0300? - l 1 RECORD DRAWING This is a permanent record and must be accurate and descriptive enough to re-local arre in ow. n ee a d f ainte existing and nance ip opas dties and futurirdsre ve opm nt wT i{went. Ty I Record ec d Drawings contain' Drainfield&manifold orientation&I.your,Septic/pump tank location. and relied permits. wells,observation ports,deanouts,and other mainten. •access points. Incomplete Record Drawings maycreate additional delays in final installation approval l ❑ Record Drawing • cached CERTIFICATION OF • INSTALLER DESIGNER/ ENGINEER I certify that I installed the system in accordance with I certify that the system has been installed in a or- the septic design stamped "APPROVED"by Mason dance with Mason Couthe septic design stamped nty Public Health and that any devOi-�1OD by County Public Health and that any deviations shown here have been cleared/approved by both the designer shown here have been cleared/approved by bo and Mason County Public Health and meet all State myself andnd Mason aso Countyouty Public ubi Health and m1 et all and Mason County Codes. odes 1 further certify that all information contained on this I further certify that all information contained on his 1 form and attached R ord Drawing is accurate. form and attached Record Drawing is accurate. 7/ /Z/ Sign ur of Install r Date • -17e ge-uSe- Printed Name of Signee MASON COUNTY PUBLIC HEALTH I The undersigned approves this Installation Report and Record Drawing on behalf of Maspn County Public I Health: p1/ \ Y Jl7/2 Signature of Environmental Health Specialist Date (stamp, signature and date) THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated Ri21/2018 • • 3d / / 1, Pipd5e1 o ow MA� \ . 1 3' ' 6CA•re4:3 e 7 "i;4 < • HTI 1 1 ( 0 ,,/ �. e' ti?. /1\ kg) 'i .. ' \O" �� .. •{ g Fel\ C &I rilu � .... _ ,, /./ ,/ 0 _ • • _„,_ _, AP L2 ''' ; '' ''''. "Si.. i --gtie- ,j• ., It 1 PROVED 4 FEB 2 7 2023 t • SON COUNTY ENVIRONMENTAL HEALD. 1 i i RET a I IE