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Home My WebLink AboutSWG2023-00097 TANK ONLY - SWG Application / Design / As-Built - 3/17/2023 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584-4 SHELTON:36027-9670,EXT 400 A- •: 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: SWG2023-00097 APPLICANT MANEMAN ET AL GREGORY D & Phone: ROBIN L Address: TYLER JAMES ADAMS & BRIANN LEE ADAMS OLYMPIA, WA 98502 OWNER MANEMAN ET AL GREGORY D & ROBIN L Phone: Address: TYLER JAMES ADAMS & BRIANN LEE ADAMS OLYMPIA,WA 98502 SEPTIC DESIGNER CINDY WAITE-Septic Designer Phone: 3607010205 Address: 80 E PICKERING LANE SHELTON, WA 98584 I Site Address: 131 W LOST LAKE VIEW DR Primary Parcel Number: 519015201004 Permit Description: Holding tank: Recreational/part-time use (RV) Permit Submitted Date: 03/17/2023 Permit Issued Date: 04/04/2023 Issued By: David Anderson Current Permit Fees Paid: $255.00 (additional fees may be required upon installation of system). Permit Expiration Date: 03/17/2026 (based on date of inspection) Type of Work OSS New Construction Components being Replaced: RV Holding Tank Surfacing Sewage? No Existing Failure? No Shoreline? No Horizontal Setbacks Met? Yes Number of Bedrooms: 1 Drinking Water Source: Public Water System Additional Details: SPS 1500P11500P-HW Permit Conditions: 4 Proposed development subject to zoning requirements and approval by the planning department staff per Mason County Title 17. 3 Mason County Asbuilt Form, Record Drawing, and Installation fee must be submitted for final installation approval. 1 Horizontal setbacks per WAC246-272A-0210 must be maintained, unless prior approval is obtained 2 Permit must be installed by a Mason County Certified Installer unA tom[ authorization from Mason County is obtained. PP ROVED ®` ,VE APR 042023 MASON COUNTY ENVIRONMFNTa1• uEALTN DJA 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. Printed From Mason County Li°vi Printed from Mason County DMS OFFICIAL USE ONLY-C CJ MASON COUNTY DATE RfCENEp c -, a COMMUNITY SERVICES AMOUNT RECEIVED'. I 1 RECEIVED BY: I.Y if �. `"t v m PublIc Health(Community Health/Environmental Health) _ y 0 J60.177-967A•a1400 0.300-275 4467,eat 400 413 IV,ntn;;roe!•Sn.ttrq WA 9F5A4 S G aba,� '-" 0( ti.t .L..-. O ON-SITE SEWAGE TANK ONLY APPLICATION xl APPLICANT PHONE m m BRIANN ADAMS J 360-580-1042 z MAILING ADDRESS-STREET.CITY.STATE.ZIP CODE C E 407 FIRE WILLOW ST NW, OLYMPIA, WA. 98502 m SITE ADDRESS•STREET,CITY,ZIP CODE j� 1"� fi �,n 1 �} • 131 W LOST LAKE VIEW DRIVE, SHELTON iti) 1 IL'U^J } �tf1' I(t) NAME OF DESIGNER PHONE MAR 17 2023 C ri?� I lee, to • 360. �' s . NAME OF INSTALL PHONE TBD By v 5 TYPE OF WORK(select ono) DRINKING WATER SOURCE cn I0 0 NEW CONSTRUCTION I UPGRADES 0 REPAIR/REPLACEMENT CIPRIVATE INDIVIDUAL WELL. 0 PRIVATE TWO-PARTY./ WELL A Z COMPCH�IENT(S)TO BE REPLACED/INSTALLED PUBLIC WATER SYSTEM �,a.f L1C, Ck f III e ❑ SEPTIC TANK 0 PUMP TANK U RV HOLDING TANK BEDROOMS LOT SIZE IL CI OTHER 5-6/ '1(/CV' �"l OTHER DETAILS(select ell that apply) TANK(S)SETBALK;:HF,CKLIS? W O pi ❑ SURFACING SEWAGE CIM EXISTING FAILURE ❑SHORELINE 100FT+PUBLIC/COMMUNITY WELLS J SUBMITTALS , OFT*PRIVATE WELLS.SURFACE WATERS.STREAMS,RIVERS I Q / a PLOT PLAN(REQUIRED) a TANK CROSS SECTION(REQUIRED) �tt1 10FT+DRINKING WATER SUPPLY LINES ❑ PUMP DETAILS(IF APPLICABLE) WAIVER(S)(IF APPLICABLE) ay 5F1+PROPERTY/EASEMENT LINES,FOUNDATIONS,FOOTINGS N PLOT PLAN CHECKLIST O I . El PROPERTY LINES AND EASEMENTS 1E3 EXISTING/PROPOSED STRUCTURES J"r EXISTING/PROPOSED OSS COMPONENTS AND LINES '-I ,,kg-EI WELLS WITHIN 100FT 0 WATER SUPPLY LINES ll4 DRIVEWAYS/PARKING SURFACE WATERS.STREAMS.RIVERS.ETC... I�' EIS DIRECTION OF SLOPE/CONTOURS ' ERIMETER/CURTAIN DRAINS Ri NORTH ARROW IV SCALE BAR DIRECTIONS TO SITE AND SITE CONDITIONS:(ex.locked gate) I GO OUT CLOQUALLUM ROAD, TURN RIGHT ONTO W LOST LAKE ROAD, TURN LEFT ONTO WQ LOST LAKE VIEW DR, TURN LEFT AT TEE, LOT IS ON THE LEFT SIDE OF ROAD, HAS A SHOP AND LARGE RV ON SITE. UPGRADE/FAILURE SOURCE(for reporting purposes) ❑VOLUNTARY 0 MAINTENANCE/PUMPING 0 BUILDING PERMIT 0 HOME SALE ❑COMPLAINT ❑OTHER: COMMENTS;CONDITIONS APPROVPIn 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 FAf(TA[7)Aiil f ROA14'f INSPE SIGNATURE DATE APPLICATION EXPIRATION DATE APPLICATION APPROVED,ISSUED BY T W�/Z0z3 3�17 Jl zG z 6 MASON COUNTY ENV!RC`!;'E;47AL HEALTH TE THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC E MASON COUNTY WEBSITE�A—_ REVISED 07/00/2019 Printed From iasoui County°' v iPrinted from Mason County DMS cindyewaite@msn.com From: brianneadams314@gmail.com Sent: Wednesday, March 15, 2023 10:31 AM To: cindyewaite@msn.com Subject: Holding tank statement Hi Cindy, I attached a copy of the signed statement that we will pump the holding tank as needed. Please let me know if you need anything else from us. Thanks, Brianne Adams OD V v i.e.-4 k a, i 5. , ,i, 433 o an tn. A‘, > E i S g i -.43. Pu 7 g. §.!! g. . i gm 17CVi. a, APPROVE' APR 0 4 2023 T MASON COUNTY ENVIRONMENTAL HEAL' s E DJ.A U ikn ES" gx c� N <xi 5 N i W Printed From Mason County DMS Printed from Mason County DMS 1 _ ( CV ha'141-7:---- N-- -� % ev,1.1 _ r O LC) fi r U 0 0 04 S J 'Af 0 Q O W 0 in g- (.0 J -LI --F-1 1-*--= .; .,.. /4PPROVP 4.:14.0 APR 0 4 2023 ., MASON COUNTY EA, _,,;i,,:_NTAL HFALT DJA Printed From Mason County DMS Printed from Mason County DMS I i — • 3-4).e/5-/acaye 1 i i j L _...._.._ _.__ _ 1 1 - �� (av' S l czcce,o f✓.saaf -- �r a��, 0 is- 60.11c i /of < 7.,x, 1 _3c), A O s 1 4. f4 r II / /a, _ r A \„ r \\ 1 1 i APPROVED E APR042023 1 i ' / MASON COUNTY ENVIRONMENTAL HEAL / 3 / w L o r Z-Al to tire DA. DJ i 57701 --1SZ— 0/do 4./ Printed From Mason Cntinty...DMsi._.. U' Printed from Mason County DMS r Liqiia 1)Pr l Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG 2023-00097 Parcel # 51901-52-01004 Applicant Name BRIANN ADAMS Subdivision (Name/Div/Block/Lot) Applicant Address 407 FIRE WILLOW ST NW City, State, Zip OLYMPIA, WA. 98502 Installer Name `d Girt/ 5 `L.r Site Address \St / /c5f/'iC L c`li CY Designer Name CINDY WAITE INSTALLATION CHECKLIST ❑ Full System Installation ❑■ Tank(s)Only ❑ Drainfield Only ❑ Repair ❑ Other System Type RV HOLDING TANK Pretreatment Type >5 ft. from foundation? - - ❑ N/A ❑■ YES ❑ NO >50 ft. from wells? - - ❑ ❑■ El Z >50 ft. from surface water? - - ❑ ❑� El 1-- Cleanout between building and tank? - - 0 ❑ ❑ o Tank baffles present? - - ❑U ❑ ❑ a24" access risers over each compartment?- - 0 ❑ ❑ uW Effluent filter installed?- - ❑■ ❑ ❑ Septic tank size 1500 gal Manufacturer HOUSE BROTHERS ❑ D-box water level and speed levelers used? - - ❑ N/A ❑ YES ❑ NO J DO Manifold/D-box accessible from surface?- - ❑ ❑ El 00 Z Check valves installed? - - ❑ ❑ ❑ ❑Q Transport Line Size Schedule/Class Bedrooms installed (check one) ❑ 2 ❑ 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other >10 ft. from foundation?- - ❑ N/A ❑ YES ❑ NO >100 ft. from wells?- � ❑ ❑ W _I >100 ft. from surface water? - `�'- - • - - -Fri ❑ ❑ ur. >10 ft. from potable water lines?- ILL ,4 ❑ ❑ ❑ Q > 5 ft. from property lines and easements?- ��t._ ❑ ❑ ❑ CC > 30 ft. from downgradient curtain/foundation drai s?-- - ❑ El ❑ Drainfield level and observation ports present - -=T _--- ❑ ❑ ❑ ❑ Graveless chambers or ❑ Clean gravel used? (check one) Proper cover installed over drainfield?- - ❑ ❑ ❑ Pump tank setbacks consistant with septic tank? - - ❑ N/A ❑ YES IN NO • Pump tank size gal Manufacturer < 24" access riser(s) and accessible from surface?- - ❑ ❑ ❑ F- a Alarm or Control Panel Installed? - - ❑ ❑ ❑ 2 Control Panel equipped with Timer/ ETM/Counter- - ❑ ❑ ❑ �� f - Pump installed in ❑ Bucket or ❑ On Block or ❑ Other a• Pump Make/Model ❑ Floats or 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 821/2C18 Mason County OSS Installation Report pg. 2 Parcel # Si*/-s'2 = /OO y ABANDONMENT RECORD Were existing septic components abandoned as part of this project? - - - - - El YES NO If yes, please describe'Were all components pumped out and properly abandoned per WAC246-272A-0300? - - EiYES 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: Dminfield&manifold orientation 8 layout.Septicfpuntp tank location,North arrow,reserve draintield,existing and proposed buildings,location of wells waterlines, wells.observation ports.deanouts.and other maintenance access points. Incomplete Record Drawings may create additional delays in final installation approval and related permits, APPROVE APR 2 7 2023 MASON COUNTY ENVIRONMENTAL HEALTH Jaw EaRecord Drawing Attached CERTIFICATION OF INSTALLATION INSTALLER DESIGNER/ ENGINEER 1 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. *frilt.__ q//2-3 i • Si at of Installer Date61/44 i� oF17 ? S i 1/1 Printed Namtof Signee �g �P :';�1,; /111 i s. `ram°A MASON COUNTY PUBLIC HEALTH o CI 51 E. 1 AITEs V The undersigned approves this Installation Report and .► Ltc sep SIGNER �1° Record Drawingon behalf of Mason CountyPublic �"� ��• �� 1 txpl Es ono/ HealtlI: Jt, 1,�,� -�3 S' nat r 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 8121/2018 . Cif • : : 3. I 1 ; L. '' =.fie 1 y sA tflagalle ri . . . qq 7 . . i - r • 14' '',,),, PP W l '”TI - la°. RO {/ o ,,,,,,,A, E APR 212023 1 I.4YI1 CC)tINTY ENVIR0NMFNTgi HEALTH o - - JBW 1,�'aQ - - ( . ' tit—hill 1 / "— /0 f i i o Jo f1� It ti0 � . Z0_ „vs . 51004 8 \A' F f I p CINDY E WAITE ; 'i 1 �r LICENSE,DESIGNER' 1� t 3 / W Lori Z-44� Y ExpiRLs .iS'c). f sci Sol # cL- p/act CIL:\#1.1 la Printed From Maso . say Printed from Mason County%IS ... . - , . / e: • tifi r,.a Ili._