HomeMy WebLinkAboutSWG2023-00047 TANK ONLY - SWG Application / Design / As-Built - 4/12/2023 OFFICIAL USE ONLY
MASON COUNTY DATE RECEIVED D 1( ll- 1 :-3 N D
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Public Health(Community Health/Environmental Health) (/)
3415 N.6th Street
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415 N.6th Street-Shelton,WA 98584 (1"' 01`,�J( (`Ju`J1 U` �
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ON-SITE SEWAGE TANK ONLY APPLICATION
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APPLICANT PHONE
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Sanet A Sane1l Frc nCO (Tay -ranco) ZOIo-3E - 3y14 Z
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MAILING ADDRESS-STREET,CITY,STATE,ZIP CODE E
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a058 NE Natalie waq ZSsgoluc 1n1 WA GI80a°I
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SITE ADDRESS-STREET,CITY,ZIP CODE
1-1y5 a E Mason LOICC, Dr. J. ra pevieM w A 61 gS4V �'
NAME OF DESIGNER PHONE IN)
NAME OF INSTALLER PHONE
Magxes EXCavafir�aJ (Gha.�eIllapFes) 31o0-UCo3- BLI9N �,,
TYPE OF ORK(select one) DRI ING WATER SOURCE -
❑ NEW CONSTRUCTION/UPGRADES g1 REPAIR/REPLACEMENT Pi PRIVATE INDIVIDUAL WELL 0 PRIVATE TWO-PARTY WELL Z p.)
COMPONENT(S)TO BE REPP CED/INSTALLED 0 PUBLIC WATER SYSTEM 1
El SEPTIC TANK F./PUMP TANK 0 RV HOLDING TANK BEDROOMS n LOT SIZE k
❑ OTHER b 0,L13
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OTHER DETAILS(select all that apply) TANK S)S BACK CHECKLIST 0
CI SURFACING SEWAGE EXISTING FAILURE 0 SHORELINE 100FT+PUBLIC/COMMUNITY WELLS ♦x
SUB ITTALS of ^ 1
SOFT+PRIVATE WELLS,SURFACE WATERS,STREAMS,RIVERS
go PLOT PLAN(REQUIRED) JTANK CROSS SECTION(REQUIRED) 1 OFT+DRINKING WATER SUPPLY LINES
❑ PUMP DETAILS(IF APPLICABLE) 0 WAIVER(S)(IF APPLICABLE) 5FT+PROPERTY/EASEMENT LINES,FOUNDATIONS,FOOTINGS
PLOT PLAN CHECKLIST O p
❑ PROPERTY LINES AND EASEMENTS 0 EXISTING/PROPOSED STRUCTURES ❑ EXISTING/PROPOSED OSS COMPONENTS AND LINES
❑ WELLS WITHIN 100FT 0 WATER SUPPLY LINES 0 DRIVEWAYS/PARKING 0 SURFACE WATERS,STREAMS,RIVERS,ETC...
❑ DIRECTION OF SLOPE/CONTOURS ❑ PERIMETER/CURTAIN DRAINS ❑ NORTH ARROW 0 SCALE BAR r, p.
DIRECTIONS TO SITE AND ITE CONDITIONS:e locked gate) P Than le- and ref tau, n e W Bee gal.
DeGOmrn��s�lUn -Faded 1V�,1_A/_J.-,�',,1
corn -rv,pte wall pui n -rank .
OFFICIAL USE ONLY BELOW THIS LINE
UPGRADE/FAILURE SOURCE((or reporting purposes)
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VOLUNTARY 0 MAINTENANCE/PUMPING 0 BUILDING PERMIT ['HOME SALE ['COMPLAINT jZOH R:
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COMMENTS/CONDITIONS frPP p
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FEB 2 2 2023
INIAIIJM'91ZEi�tE B UlREME NT4,EQUIPPED WITH RISERS
SEWAGE TANKS MUST BE LISTED UNDER DOH"LIST OF REGISTERED SEWAGE TANKS'. TANKS MUS1'tGfEWNL1�REfV: tt��
AND LIDS TO SURFACE,AND INCLUDE AN EFFLUENT FILTER(IF APPLICABLE). RECORD DRAWING AND INSTALLATION REPOR RT UIRED FOR FINAL APPROVAL.
INSPECTOR SIGNATURE DATE APPLICATION EXPIRATION DATE APPLICATION APPROVED/ISSUED BY DATE
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THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE REVISED 12/7/2015
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'' i • VERIFY PROPERTY LINES .
• •' .. AND SETBACKS: FOR NEW
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FEB 2 2 2023 jj
NTAL HEALTH' � :.1 ;•• • y. : '••,.::a ••' ' '• •• ' ;� . •
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- I P,,V.E;TWO DESIGN FORD - PAGE ONE �s..d O6/2O 92
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•Applicant's Name Bjnb le,„.;be 1 22ti r_. Prop. Owner's Name Dan )2 ee Q
Mailing Address ? 6,3 x 4 3 G Prop. Street Address 3l5 /yth t't S,--4i,
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No. Bedrooms _ Daily Plow 3�Dgpd . Soil Type Gocrh,", SQ,r,�Q 0ea Gt^co-ve.
Septic.;Tank Capacity f�Oo '1 gallons Native Soil Application Rate 'SAS qpd/ft3 •
Site Characters 0 Level Sloping Trench/Bed Bottom Area 6> 4''f ft2
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Length. /3 O ft' Length li£ • ft Length • ? e, ft
Diameter , • in Diameter in Diameter / in
Number 5-
Separation /o ft
Pump/Siphon and (Morahan . ,
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Capacity al.•Pressure Head
P Y at T t A ,,T.5 ?G orifices
Calculated Total _Pressure Head tg Lz 3Q.,2(7, ft .
Number of Dosee�per: Day Number/Lateral Pair /O
Dose Quantity 0 L.O gal Diameter �//6 in
Chamber Capacity. or, al Spacing 3 ' ?
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Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWGPO.23-0OC41 Parcel #as ?53-'71 - 00010
Applicant Name jOnakSaneII TOnCO Subdivision (Name/Div/Block/Lot)
Applicant Address 02052 N E N611I e J&1 M(d,nr'( .Sunny ch we A&1 t-5 W. 10
City, State, Zip .ZcsoiC1UG1 V , WA°I f8d'1 Installer Name Maip1c( ExCava-hnc1
Site Address LP-15 l:. Ma 1 ICI ke oilw. Designer Name
INSTALLATION CHECKLIST
❑ Full System Installation [`i Tank(s) Only ❑ Drainfield Only ❑ Repair ❑Other
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System Type i ' es ore, Pretreatment Type
>5 ft. from foundation? - - ❑ NIA ❑YES ❑ NO
>50 ft. from wells? - - ❑ ❑ ❑
Z >50 ft. from surface water? - - ❑ ❑ El
< Cleanout between building and tank? - rr ( El El El
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Tank baffles present? - ,'Z tl-dH !❑ ❑ ❑
d 24" access risers over each compartment?- -- - ElEl❑
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W APB_(La 2023-
❑ El ElEffluent filter installed?-
Septic tank size t?Q'Qi gal ' Manufactlr r
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0 D-box water level and speed levelers used? - ----❑ N/A ❑ YES ❑ NO
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>8O Manifold/D-box accessible from surface? - ❑ El
CUE Check valves installed? - - ❑ ❑ El
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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
O >100 ft. from wells?- - ❑ ❑ ❑
WEl>100 ft. from surface water? - - ❑ ❑
LL >10 ft. from potable water lines?- - ❑ El ❑
Z > 5 ft. from property lines and easements?- - El El El
a El ❑ El
Q > 30 ft. from downgradient curtain/foundation drains?- -
Drainfield level and observation ports present - El El ❑
❑ Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - El El ❑
Pump tank setbacks consistant with septic tank? - - ❑ N/A [ YES ❑ NO
Pump tank size 'we, gal Manufacturer KC 1 h
< 24" access riser(s) and accessible from surface?- - ❑ L.� ❑
~ Alarm or Control Panel Installed? - - El IQ ❑
°' El El ❑
E Control Panel equipped with Timer/ ETM /Counter- -
D
n- Pump installed in ❑ Bucket or [ "On Block or El Other
a. Pump Make/Model [h RMI- 1000 E Floats or ❑ Transducer
0_
a Tank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
Upda:e 1 8: V2018
Mason County OSS Installation Report pg. 2 Parcel# 000l�
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - ❑ YES ❑ NO
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - ❑ 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 I 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
I 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.
31311 a
Signature of Installer Date
Sht 'le Moutolec
Printed Name of Signee
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public
Health:
Signa e ironmental Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 821/2018
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RECORD DRAWING (continued)
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