HomeMy WebLinkAboutSWG2023-00123 - SWG Application / Design - 4/3/2023 •
• 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 Tank Only Permit: SWG2023-00123
APPLICANT WETZEL CHARLES A & KAY F Phone: 1.253.208.8156
Address: 11412 88th Avenue E PUYALLUP, WA 98373
OWNER WETZEL CHARLES A & KAY F Phone: 1.253.208.8156
Address: 11412 88th Avenue E PUYALLUP, WA 98373
SEPTIC INSTALLER JACK JOHNSON-Jack Johnson Phone: 1.360.277.5400
Construction
Address: P 0 BOX 1119 BELFAIR, WA 98528
Site Address: 464 E TREASURE ISLAND DR
Primary Parcel Number: 121055200068
Permit Description: Replace septic and pump tank
Permit Submitted Date: 04/03/2023
Permit Issued Date: 04/03/2023
Issued By: Rhonda Thompson
Current Permit Fees Paid: $255.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 04/03/2024 (based on date of inspection)
Type of Work OSS Repair
Components being Replaced: Septic and Pump Tanks
Surfacing Sewage? No Existing Failure? Yes
Shoreline? No Horizontal Setbacks Met? Yes
Number of Bedrooms: 2 Drinking Water Source: Public Water System
Additional Details: Septic and pump tank
Permit Conditions:
2 Permit must be installed by a Mason County Certified Installer unless prior written
authorization from Mason County is obtained.
1 Horizontal setbacks per WAC246-272A-0210 must be maintained, unless prior approval is
obtained
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.
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.
OFFICIAL USE ONLY
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ON-SITE SEWAGE TANK ONLY APPLICATION D
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APPLICANT PHONE m rn
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MAILING ADDRESS-STREET.CITY,STATE.ZIP CODE g
1 I /1 5g til /v F AAye, lltAP I✓4 15375- 3,5297 co
SITE ADDRESS-STREET,CITY,ZIP CODE
4 NAME OF DESIGNER PHONE
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NAME OF INSTALLER PHONECI r
is k 111/1. m jw6olnSiAI qg )4.cam 30 3 yU-- I "7 7
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TYPE OF WORK(select one) DRINKING WATER SOURCE
❑ NEW CONSTRUCTION/UPGRADES , REPAIR/REPLACEMENT 0 PRIVATE INDIVIDUAL WELL 0 PRIVATE TWO-PARTY WELL Z {,j'1
COMPONENT(S)TO BE REPLACED/INSTALLED / ` ,�PUBLIC WATER SYST I
SEPTIC TANK APUMP TANK 0 RV HOLDING TANK BEDRO/S LOT SIZE 1.--f l
❑ OTHER - , 1 7 ?L(�f W
OTHER DETAILS(select all that apply t TANK(S)SETBACK CHECKLIST r J�-'
❑ SURFACING SEWAGE EXISTING FAILURE 0 SHORELINE 100FT+PUBLIC/COMMUNITY WELLS P.
SUBMITTALS Al/SOFT+PRIVATE WELLS,SURFACE WATERS,STREAMS.RIVERS
4 PLOT PLAN(REQUIRED) TANK CROSS SECTION(REQUIRED) 1OFT+DRINKING WATER SUPPLY LINES
❑ PUMP DETAILS(IF APPLICAB E) ❑ WAIVER(S)(IF APPLICABLE) 5FT+PROPERTY/EASEMENT LINES.FOUNDATIONS,FOOTINGS
PLOT PLAN CHECKLIST r I
;tL PROPERTY LINES AND EASEMENTS 4'EXISTING!PROPOSED STRUCTURES AI EXISTING/PROPOSED OSS COMPONENTS AND LINES
❑ WELLS WITHIN 100FT 0 WATER SUPPLY LINES ; I DRIVEWAYS/PARKING 0 SURFACE WATERS,STREAMS,RIVERS,ETC...
❑ DIRECTION OF SLOPE/CONTOURS ❑ PERIMETER/CURTAIN DRAINS 0 NORTH ARROW 0 SCALE BAR I' IC
DIRECTIONS TO SITE AND SITE CON1D__ITIONS.(ex.locked gate) I
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OFFICIAL USE ONLY BELOW THIS LINE
UPGRADE/FAILURE SOURCE(for reporting purposes)
❑VOLUNTARY MAINTENANCE/PUMPING 0 BUILDING PERMIT 0 HOME SALE ['COMPLAINT 0 OTHER:
COMMENTSn_ I CONDITIONS I L (M T R 'f l T
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SEWAGE TANKS MUST BE LISTED UNDER DOH'LIST OF REGISTERED SEWAGE TANKS'. TANKS MUST ET CIJRREN, M SIZE REQUI (NTS,EQUIPPED WTH RISERS
AND LIDS TO SURFACE,AND INCLUDE AN EFFLUENT FILTER(IF APPLICABLE). RECORD DRAWING AND i U.AT1QN, -_lON REPORT REQUIRED FOR FI(rIALAPPROVAL.
INSPECTOR SIGNATURE DATE APPLICATION EXPIRATION DATE y APPLICCA 1ONARO ISSUED BY DATE
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THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE 4 REVISED 7/9/2019
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APPROVED
APR 0 3 2023
MASON COUNTY ENVIRONMENTAL HEALTH
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Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2023-00123 Parcel # 121055200068
Applicant Name Wetzel Charles A& Kay F Subdivision (Name/Div/Block/Lot)
Applicant Address 11412 88th ave E
City, State, Zip Puyallup, WA 98373 Installer Name Jack Johnson
Site Address 464 E Treasure island dr Designer Name
INSTALLATION CHECKLIST
❑ Full System Installation ® Tank(s)Only ❑ Drainfield Only ❑Repair ❑ Other
System Type Shallow pressure(PSD) Pretreatment Type
1
>5 ft. from foundation? - ( ❑ N/A ElYES ❑ NO
>50 ft. from wells? - I `�-�-� +'1- -
A El
Z• >50 ft. from surface water? APR 2 7 2023 ❑ * El
Cleanout between building and tank? - - - - I� ❑ ❑
H
U Tank baffles present? - 13y - - - - - - ❑ U ❑
a24" access risers over each compartment?- - - - - - =_ - - ❑ ME El
W Effluent filter installed?- - ❑ 0 ❑
rn
Septic tank capacity (working) 1000 gal Manufacturer Hagerman
0 D-box water level and speed levelers used? - - ® N/A ❑ YES ❑ NO
�OJ Manifold/D-box accessible from surface?- - ® ❑ ❑
co Z Check valves installed? - - 0 ❑ ❑
thQ
2 Transport Line Size 2" Schedule/Class 40
Bedrooms installed (check one) 42 ❑ 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- - ❑ N/A ❑ YES ❑ NO
>100 ft. from wells?- - ❑ ❑ ❑
W >100 ft. from surface water? - •- El El
u. >10 ft. from potable water lines?- .- ❑ ❑ ❑
Z > 5 ft. from property lines and easements?- - ❑ ❑ ❑
4 Q
a > 30 ft. from downgradient curtain/foundation drains? - - ❑ ❑ ❑
o
Drainfield level and observation ports present - - ❑ ❑ ❑
❑ Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ ❑ ❑
Pump tank setbacks consistent with septic tank? - - ❑ N/A U YES ❑ NO
I Pump tank capacity (flood) 1000 gal Manufacturer Hagerman
Q24" access riser(s)and accessible from surface? El ❑
H
a Alarm or Control Panel Installed? - - ❑ U ❑
2 Control Panel equipped with Timer/ ETM /Counter- - ❑ ❑ 0
D
a Pump installed in ❑ Bucket or 0 On Block or ❑ Other
a• Pump Make/Model liberty 280 ® Floats or ❑ Transducer
a. Tank draw down 2°
a in/min Pump capacity 40 gpm Squirt Height ft
Pump on time manual Pump off time maNUAL Daily flow set at 240 gpd
Updated 8,21'2018
y
Mason County OSS Installation Report pg. 2 Parcel 05 - 5.1-00( 8
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - YES NO
If yes, please describe:
Were all components pumped out and property abandoned per WAC246-272A-0300? - - III YES El NO
RECORD DRAWING
This is a permanent record and must be accurate and descriptive enough to relocate in the need of maintenance acttvtties and future development. Typical Record
Drawings contain' Dranfield&manifold onentaton&layout.Septic/pump tank location.North arrow,reserve drainfield,eiesting and proposed builtrngs,location of wells,waterlines,
wells.observation ports,deanouts,and other mamtonance access pants. Incomplete Record Drawings may create additional delays in final installation approval and related peanuts.
III Record 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 nd att ed Record Drawing is accurate. form and attached Record Drawing i$accurate.
4-ZI -23
S• re off taller Date
-3-6kL k �d hnSr�f�
Printed Name of Signee
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public
Health:
RtiValyC‘14(1
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 8i2t.cle
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