HomeMy WebLinkAboutSWG2023-00128 - SWG Application / Design - 4/7/2023 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON:360-427-9670,EXT 400
J _ BELFAIR:360-275-4467,EXT 400
Public Health & Human Services ELMA:360-482-5269, EXT 400
FAX:360-427-7787
On-Site Sewage System Tank Only Permit: SWG2023-00128
OWNER MACERO LF EST ET AL DOROTHY Phone:
Address: 3770 NW Linden Lane BREMERTON, WA 98312
APPLICANT MACERO LF EST ET AL DOROTHY Phone:
Address: 3770 NW Linden Lane BREMERTON, WA 98312
SEPTIC INSTALLER DARYL HEMLEY- Ron Hemley Septic Phone: 253-857-3241
Address: PO BOX 305 BURLEY, WA 98322
Site Address: 61 NE CREEKVIEW PL
Primary Parcel Number: 223315000063
Permit Description: Replace Norweco with Nuwater BNR500
Permit Submitted Date: 04/07/2023
Permit Issued Date: 04/10/2023
Issued By: Rhonda Thompson
Current Permit Fees Paid: $255.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 04/10/2024 (based on date of inspectior)
Type of Work OSS Repair
Components being Replaced:
Surfacing Sewage? Existing Failure?
Shoreline? Horizontal Setbacks Met?
Number of Bedrooms: Drinking Water Source:
Additional Details:
Permit Conditions:
2 Permit must be installed by a Mason County Certified Installer unless prior written
authorization from Mason County is obtained.
5 Installer is responsible for obtaining Septic Designer/Engineer installation approval prior to
backfill of system components.
1 Proposed development subject to zoning requirements and approval by the planning
department staff per Mason County Title 17.
6 Mason County Asbuilt Form, Record Drawing, and Installation fee must be submitted for
final installation approval.
4 Installer is responsible for obtaining Mason County installation approval prior to backfill of
system components.
3 Drain field installation not to exceed designed upslope and downslope depth specified on
design form.
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: masoncountywa.gov/health/environmental/onsiteloss-inspection-request.php or call:
360-427-9670, extension 400.
0 OFFICIAL USE ONLY
DATE RECEIVED
m.o.,p tia,. MASON COUNTY ' Z cn D
COMMUNITY SERVICES AMOUNT RECEIVED: D RECENED BY: CO �
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, `tom Public Health(Community Health/Environmental Health) g.:'., O p.
360-427-9670,eal.400 or 360-275.4467,eat.400
4 I 5 N.6th Street-Shrbon.WA 90594 S W G Z 2. - p p/25 o
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ON-SITE SEWAGE TANK ONLY APPLICATION
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APPLICANT PHONE r
Brcicl bame 3ro r\ 36,0 r o - 71(3/
MAILING ADDRESS-STREET,CITY,STATE.ZIP CODE I g
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SITE ADDRESS-STREET,CITY.ZIP CODE
NAME OF DESIGNER ' PHONE
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NAME OF INSTALLER PHONE LA/'
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TYPE OF WORK(select ova) DRINKING WATER SOURCE O
❑ NEW CONSTRUCTION/UPGRADES 'REPAIR/REPLACEMENT 0 PRIVATE INDIVIDUAL WELL ❑ PRIVATE TWO-PARTY WELL Z
COMPONENT(S)TO BE REPLACED/INSTALLED 7�'r PUBLIC WATER SYSTEM - 1
❑ SEPTIC TANK 0 PUMP TANK 0 RV HOLDING TANK BEDROOMS LOT SIZE ny�s� v)
OTHER Tg-E4-trkirrsfr TA-me--. 2 10/ ,4t R S co o
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OTHER DETAILS(select all that apply) TANK(S)SETBACK CHECKLIST Q
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❑ SURFACING SEWAGEittY
EXISTING FAILURE 0 SHORELINE . 100FT+PUBLIC/COMMUNITY WELLS
SUBMITTALS g+ SOFT+PRIVATE WELLS,SURFACE WATERS,STREAMS,RIVERS
t PLOT PLAN(REQUIRED) ,TANK CROSS SECTION(REQUIRED) '13pi/
10FT+DRINKING WATER SUPPLY LINES
❑ PUMP DETAILS(IF APPLICABLE) 0 WAIVER(S)(IF APPLICABLE) Ii,.'5FT*PROPERTY/EASEMENT LINES,FOUNDATIONS,FOOTINGS
PLOT PLAN CHECKLIST Q 0
PROPERTY LINES AND EASEMENTS iziEXISTING!PROPOSED STRUCTURES y�EXISTING!PROPOSED OSS COMPONENTS AND LINES
i/Q�-WELLS WITHIN 100FT WATER SUPPLY LINES �,DRIVEWAYS/PARKING ¢Ll SURFACE WATERS.STREAMS,RIVERS,ETC...
p" DIRECTION OF SLOPE/CONTOURS )'4PERIMETER/CURTAIN DRAINS g NORTH ARROW p$SCALE BAR
DIRECTIONS TO SITE AND SITE CONDITIONS:(ex.locked gate)
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UPGRADE I FAILURE SOURCE(for repo/hog purposes)
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ID VOLUNTARY)4MAINTENANCE/PUMPING 0 BUILDING PERMIT ❑HOME SALE ❑COMPLAINT El OTHER: \/N
COMMENTS I CONDITIONS O
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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
LA 1 1 (214 izrwprall Al ( Ott_
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE REVISED 127/2015
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