HomeMy WebLinkAboutSWG2023-00139 TANK ONLY - SWG Application / Design - 4/18/2023 6TH STREET,SHELTON,WA 98584
LL MASON COUNTY 415 N 6 SHELTON:360-427-9670,EXT 400
BELFAIR:360-275-4467,EXT 400
� - e. Public Health & Human Services ELMA: 360-482-5269, EXT400
FAX:360-427-7787
On-Site Sewage System Tank Only Permit: SWG2023-00139
OWNER 768BIGBUDDHA LLC Phone:
Address: 2033 6TH AVE STE 920 SEATTLE, WA 98121
APPLICANT 768BIGBUDDHA LLC Phone:
Address: 2033 6TH AVE STE 920 SEATTLE, WA 98121
SEPTIC INSTALLER Shane Maples- MAPLES EXCAVATING Phone: 360-463-8474
Address: 911 SE Arcadia Road SHELTON, WA 98584
Site Address: 22990 N US HIGHWAY 101
Primary Parcel Number: 422235000012
Permit Description: Replace septic tank ATF permit
Permit Submitted Date: 04/18/2023
Permit Issued Date:
Issued By: Rhonda Thompson
Current Permit Fees Paid: $255.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 04/18/2026 (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? No
Number of Bedrooms: 3 Drinking Water Source: Public Water System
Additional Details: Roth 1250
Permit Conditions:
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
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.
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.
iii/ OFFICIAL USE ONLY
MASON COUNTY DATE RECENED `' - ilk
-I I. -- COMMUNITY SERVICES AMOUR RECEI W CD
Public Health (Community Health/Environmental Health) C
41SN. thStreet-Selo Shelton.
5-Su ext.400 SWG z3 - as % Vi 0 2
47 S N.bth Street-Sheaon,WA 98584
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ON-SITE SEWAGE TANK ONLY APPLICATION
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APPLICANT PHONE m
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768Bigbuddha LLC z
MAILING ADDRESS-STREET,CITY,STATE,ZIP CODE g
7662 S. Lakeridge Dr. Seattle,WA 98178 co
SITE ADDRESS-STREET,CITY,ZIP CODE
22990 N US HWY 101 Hoodsport, WA 98548 [-E-
NAME OF DESIGNER PHONE
NAME OF INSTALLER PHONE 0 I
Maples Excavating 360-463-8474 <_
TYPE OF WORK(select one) DRINKING WATER SOURCE
❑ NEW CONSTRUCTION/UPGRADES in REPAIR/REPLACEMENT 0 PRIVATE INDIVIDUAL WELL 0 PRIVATE TWO-PARTY WELL Z IW
COMPONENT(S)TO BE REPLACED/INSTALLED ElPUBLIC WATER SYSTEM Eli Icl
GI SEPTIC TANK ❑ PUMP TANK 0 RV HOLDING TANK BEDROOMS LOT SIZE I(.in
❑ OTHER , 3 .28 OTHER DETAILS(select all that apply) TANK(S)SETBACK CHECKLIST rW 10
t
❑ SURFACING SEWAGE in EXISTING FAILURE 0 SHORELINE in 100FT+PUBLIC/COMMUNITY WELLS 0I O
SUBMITTALS El50FT+PRIVATE WELLS,SURFACE WATERS,STREAMS,RIVERS
113 PLOT PLAN(REQUIRED) In TANK CROSS SECTION(REQUIRED) pp 10FT+DRINKING WATER SUPPLY LINES I C
❑ PUMP DETAILS(IF APPLICABLE) 0 WAIVER(S)(IF APPLICABLE) $1 5FT+PROPERTY/EASEMENT LINES,FOUNDATIONS,FOOTINGS
PLOT PLAN CHECKLIST 0 1" IO
❑ PROPERTY LINES AND EASEMENTS 0 EXISTING/PROPOSED STRUCTURES 0 EXISTING/PROPOSED OSS COMPONENTS AND LINES —I
❑ WELLS WITHIN 100FT ❑ WATER SUPPLY LINES 0 DRIVEWAYS/PARKING 0 SURFACE WATERS,STREAMS,RIVERS,ETC... I----.
❑ DIRECTION OF SLOPE/CONTOURS ❑ PERIMETER/CURTAIN DRAINS 0 NORTH ARROW 0 SCALE BAR
DIRECTIONS TO SITE AND SITE CONDITIONS:(ex.locked gate)
Replaced 750 gallon septic tank with a 1250 Roth septic tank in same location.
OFFICIAL USE ONLY BELOWTHIS LINE
UPGRADE/FAILURE SOURCE(for reporting purposes)
❑VOLUNTARY AINTENANCE/PUMPING 0 BUILDING PERMIT ❑HOME SALE ['COMPLAINT ❑OTHER: n (� ('f {�;? 7
COMMENTS/CONDIT ONS �v", (� �'
APR 18 Z023
4pkojt vpi-i c iah 1 ,
SEWAGE TANKS MUST BE LISTED UNDER DOH'LIST OF REGISTERED SEWAGE TANKS". TANKS MUST MEET CURRENT MINIMUM SIZE t
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
i -- H (« IN tap 't 1 iG 1 ZS
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE REVISED 12/7/2015
Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Li
Permit Number SWG Parcel # `i 2 Z23_5 0 — CS-L.)0 t2
Applicant Name 1( b vc k k'&.. LLC, Subdivision (Name/Div/Block/Lot)
Applicant Address 1(6(17 S l GoY,ufAV, 011
City, State, Zip lC1 t1%1 (� Installer Name �(X9\QS EX((t, (.hY1.G1
Site Address ZZ4go N Ui l`w'( NI Designer Name JJ
INSTALLATION CHECKLIST
El Full System Installation Tanks)Only El Drainfield Only El Repair El Other
System Type ClaViAl.i Pretreatment Type
>5 ft.from foundation? - - MN/A ❑YES ❑ NO
>50 ft.from wells? - •- ❑ ❑
Z >50 ft.from surface water? - - CI CI12'
HCleanout between building and tank? - - ❑ 0. 0
V Tank baffles present? - - ❑ 21 ❑
a24" access risers over each compartment?- - ❑ El CI
W Effluent filter installed?- - ❑ ill ❑
U)
Septic tank capacity (working) \2,50 gal Manufacturer (&C)\--
5 D-box water level and speed levelers used? - - ❑ N/A ❑ YES 0 NO
oO Manifold/D-box accessible from surface?- - CI CI CI
C92 Check valves installed? - - ❑ ❑ ❑
CiQ
2 Transport Line Size Schedule/Class
Bedrooms installed (check one) ❑ 2çZf3
El El El ❑Commercial/Other
>10 ft.from foundation? - - ❑ N/A ❑ YES ❑ NO
CI >100 ft. from wells?- - ❑ ❑ ❑
U.1 >100 ft.from surface water? - - CI CI CI
T. >10 ft.from potable water lines?- - ❑ ❑ ❑
Z > 5 ft.from property lines and easements?- - ❑ ❑ ❑
Q
cc > 30 ft.from downgradient curtain/foundation drains? - - ❑ ❑ ❑
Drainfield level and observation ports present - - ❑ ❑ ❑
El Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ ❑ ❑
Pump tank setbacks consistent with septic tank? - - ❑ N/A ❑ YES El NO
• Pump tank capacity(flood) gal Manufacturer
< 24" access riser(s) and accessible from surface?- - ❑ ❑ ❑
F-
a Alarm or Control Panel Installed? - - CI CI
E Control Panel equipped with Timer/ETM /Counter- - ❑ ❑ ❑
D
a. Pump installed in ❑ Bucket or El On Block or El Other
a• Pump Make/Model El Floats or El Transducer
a
Tank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
Updated 8.'21/2018
Mason County OSS Installation Report pg. 2 Parcel#
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - ViYES NO
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - ❑ YES El 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.
b A olds-Si-' .
IV) 51- O
1(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.
Signature of Installer Date
Sh o.v•e- ' G e<<5
Printed Name of Signee
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public
Health:
elpaMec.211 V1 I (G (z 3
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 8;21/2018
RECORD DRAWING (continued)
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