HomeMy WebLinkAboutSWG2022-00403 - SWG Application / Design - 7/13/2022 alk: MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON:360-427-9670,EXT 400
BELFAIR:360-275-4467,EXT 400
—�_ Public Health & Human Services ELMA:360-482-5269, EXT 400
FAX:360-427-7787
On-Site Sewage System Permit: SWG2022-00403
APPLICANT SIMONS PHILIP C & DEBRA L Phone:
Address: 1133 N GRAPE DR APT C 203 MOSES LAKE, WA 98837
OWNER SIMONS PHILIP C & DEBRA L Phone:
Address: 1133 N GRAPE DR APT C 203 MOSES LAKE, WA 98837
SEPTIC DESIGNER ROD LEFT-Acme Design Phone: 360-509-2000
Address: PO Box 2954 SILVERDALE, WA 98383
Site Address: 1290 E TIMBER TIDES DR
Primary Parcel Number: 322354390162
Permit Description: New 4bd gravity trench with Class B waiver
Permit Submitted Date: 07/13/2022
Permit Issued Date: 04/12/2023
Issued By: Rhonda Thompson
Current Permit Fees Paid: $500.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 07/22/2025 (based on date of inspection)
Permit Conditions:
1 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 Drain field installation not to exceed designed upslope and downslope depth specified on
design form.
4 Installer is responsible for obtaining Mason County installation approval prior to backfill of
system components.
5 Installer is responsible for obtaining Septic Designer/Engineer installation approval prior to
backfill of system components.
6 Mason County Asbuilt Form, Record Drawing, and Installation fee must be submitted for
final installation approval.
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 DESIGN APPROVED.
FINAL INSTALLATION APPROVAL IS REQUIRED PRIOR TO TEMPORARY OR FINAL OCCUPANCY OF ANY RELATED STRUCTURES.
For Final Inspection visit: masoncountywa.gov/health/environmental/onsiteloss-inspection-request.php or call:
360-427-9670, extension 400.
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ON-SITE SEWAGE SYSTEM APPLICATION D D
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APPLICANT n
PHONE m m
PHILIP SIMONS
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MAILING ADDRESS-STREET,CITY,STATE,ZIP CODE C
2754 RUSHLAND PARK BLVD KNOXVILLE TN 37924 m
SITE ADDRESS-STREET,CITY,ZIP CODE
1290 E TIMBER TIDES DR UNION WA 98592 W
NAME OF DESIGNER
PHONE
ROD LEFT 360-698-8488 M
NAME OF INSTALLER PHONE I N
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C
PERMIT TYPE(select one) p DRINKING WATER SOURCE — I W
I RESIDENTIAL OSS COMMUNITY OSS COMMERCIAL OSS PRIVATE INDIVIDUAL WELL I U�'}PRIVATE TWO-PARTY WELL 0
LI
TYPEPE OF WORK(select one) �j PUBLIC WATER SYSTEMCTI
@q�NEW CONSTRUCTION I UPGRADES EREPAIR/REPLACEMENT OTHER DETAILS(select elf that apply) ❑TABLE IX REPAIR I .ij
SUBMITTALS ElSURFACING SEWAGE 0 EXISTING FAILURE ❑SHORELINE
ZDESIGN FORM(REQUIRED) SEPTIC DESIGN(REQUIRED) BEDROOMS LOT SIZE o
q I W
Ltt JWAIVER(S)(IF APPLICABLE) 4 55,756.8 o
DIRECTIONS TO SITE AND SITE CONDITIONS:(ex.locked gate) -- I (CI
SEE MAP Io
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SITE MUST BE FLAGGED FROM MAIN ROAD AND TEST HOLES MUST BE FLAGGED WITH TEST HOLE NUMBERS. I N
OFFICIAL USE ONLY BELOW THIS LINE
UPGRADE/FAILURE SOURCE(for reporting purposes)
0 VOLUNTARY 0 MAINTENANCE/PUMPING ❑BUILDING PERMIT CI HOME SALE ['COMPLAINT ❑OTHER:
INSPECTOR SOIL LOGS COMMENTS/CONDITIONS
14 o J3-7 Cis t- 4 OP
�--11- ii 11 -A3: p-I`-1
1W b-zQ/30 GSA )\I?o 1"
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SOIL CODES: RECORD DRAWING AND INSTALLATION REPORT
V=VERY G=GRAVELLY S=SAND L=LOAM Si=SILT C=CLAY E=EXTREMELY R=ROOTS REOUIRED FOR FINAL APPROVAL.
INSPECTOR SIGNATURE DATE APPLICATION EXPIRATION DATE APPLICATION APPROVED/ISSUED BY DATE
Ili ,, WO 7 /Lz "7112/ `-tf`z[z _
THIS FORM MAY-E SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE REVISED 12///2015
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DESIGN FORM-PAGE ONE Assessor's Parcel Number: 3 2 2 3 5 — 4 3 — 9 0 1 6 2
A design will be reviewed when 3 copies of each of the following are submitted:
`'Completed design form that has been signed and dated. '"Scaled layout sketch,including all applicable items on checklist
Scaled plot plan,including all applicable items on checklist. Cross-section sketch,including all applicable items on checklist.
This form may be scanned and available for public view on the Mason County Web site.Maximum z ��. paper size: 11' X 17"
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Permit Number: SWG `192 -. 00 L4.03 Designer's Name: ROD LEFT
Applicant's Name: Designer's SIMONS Designer's Phone Number: 360-698-8488
Mailing Address: 2754 RUSHLAND PARK BLVD Designer's Address: PO BOX 2954
KNOXVILLE TN 37924 SILVERDALE WA 98383
±, Sy'.}QCYc City State ZipState
{e '�WP '�?` -`�,3~F 4. .,. ,. • .b �City Zip
Treatment Device
❑Glendon Biofilter 0 Sand Filter 0 Mound 0 Sand Lined Drainfield 0 Recirculating Filter,Type:
❑Aerobic Unit MakelModel 0 Disinfection Unit Make/Model Other:
Drainfield Type
l 'Gravity 0 Pressure 0 Trench 0 Bed 0 Sub Surface Drip
Septic Tank/Drainfield Specifications Laterals
Number of Bedrooms 4 Schedule/Class 40
Daily Flow:Operating Capacity 480 5l„i7 gpd Length S S ft
Daily Flow:Design Flow 480 gpd Diameter 4 in
Septic Tank Capacity 1250 gal Number 5
Receiving Soil Type(1-6) 4 Separation 5 ft
Receiving Soil Appl.Rate .6 gpd/ft2 Orifices
Required Primary Area 800 ft2 Total Number of Orifices
Designed Primary Area $edtiec ft2 Diameter
in
Designed Reserve Area fir tZ5ft2 Spacing
in
Trench/Bed Width 3 Manifold
Trench/Bed Length O zic ft Schedule/Class
Elevation Measurements Length ft
Original Drainfield Area Slope 5-7 % Diameter in
New Slope,If Altered 5-7 % Preferred manifold configuration used? 0 Yes 0 No
Depth of Excavation Up-slope 9 in Transport Pipe
from Original Grade Down.siope 7
in Schedule/Class 40
Designed Vertical Separation 18 in Length Z O ft
Gravelless Chambers Required? 0 Yes 0 No el Optional Diameter 4 in
Pump Required? 0 Yes 'No
Dosing and Pump Chamber
Pump/Siphon Specifications Number of doses/day
Difference in Elevation Between Pump Shutoff and Uppermost Dose quantity gal
Orifice ft Chamber Capacity gal
Uppermost Orifice 0 Higher 0 Lower than Pump Shutoff Pump controls:Please check those required.
Capacity @ Total Pressure Head gpm ❑Timer ❑Elapse Meter 0 Event Counter
Calculated Total Pressure Head ft If Timer: Pump on Pump off
Comments
CLASS B WAIVER
DESIGN FORM-PAGE TWO Assessor's Parcel Number:3 2 2 3 5 -- 4 3 -- 9 0 1 6 2
Permit Number: SWG
DESIGN CHECKLISTS
Scaled Plot Plan Scaled Layout Sketch Cross-Section Sketch
liti Test hole locations 6d Drainfield orientation and layout Reference depth from original grade:
6d Soil logs Ei Trench/bed dimensions and lif Septic tank
121 Property lines critical distances within layout l0 Drainfield cover
IZI Existing and proposed wells Eg D-Box/Valve box locations Reference depth from original grade
within 100 ft of property Eil Septic tank/pump chamber and restrictive strata:
❑ Measurements to cuts,banks,and locations Gd Laterals,trench bed,top and
surface water and critical areas 121 Observation port location bottom
❑ Location and orientation of (2f Clean-out location 0 Curtain drain collector
curtain drain and all absorption 0 Manifold placement 0 Sand augmentation
components 0 Orifice placement
Other cross-section detail:
66 Location and dimension of Observation
primary system and reserve area Et Lateral placement with distance ports/clean-outs
to edge of bed
121 Buildings Other Information
0 Audible/visual alarm referenced Yes No
E,i Direction of slope indicator
Lid Scale of drawing shown on scale 0 lt Design staked out
10 Waterlines bar ❑ Ed Recorded Notices attached
EA Roads,easements,driveways, Iii 0 Waiver(s)attached
parking 0 F2f Pump curve attached
lid North arrow and scale drawing 0 tip Evaluation of failure
shown on scale bar Non-residential justification
❑ Er Waste strength
❑ O Flow
DESIGN APPROVAL
The undersigned designer must be notified by .nstall at time of installation tip Yes 0 No
-1•E3•ZoZL
S. e of Designer Date
The undersigned has reviewed this design on behalf of Mason County Public Health and determined it to be in
compliance with state and local on-site regulations:
L-tt
(-42,3
Environmental Health Speciali t ate
CAUTION: DESIGN APPROVAL IS VALID ONLY UNDER THE FOLLOWING CONDITION:
✓ The design is stamped"Approved"by Mason County Public Health. /
✓ The Onsite Sewage Permit has not expired,the Permit Expiration Date is: -1 1 Z2-1^�
�iS
✓ Drainfield site conditions have not been altered to adversely affect conditions of design approval.
Please Note: The system must be installed by a certified installer,
unless prior authorization is obtained from Mason County Public Health.
An Installation Fee is required.
This form may be scanned and available for public view on the Mason County Web site.
Updated Date: 12/7/2015
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