HomeMy WebLinkAboutSWG2023-00153 TANK ONLY - SWG Application / Design - 4/27/2023 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: SWG2023-00153
APPLICANT Michael Trotter Phone:
Address: 3831 W Fish Hatchery Rd ELMA, WA 98541
SEPTIC INSTALLER KREG KADOUN- FIVE GUYS Phone: 360-432-0971
EXCAVATING INC
Address: PO BOX 129 SHELTON, WA 98584
OWNER TROTTER MICHAEL J & RACHEL Phone:
Address: 1001 COOPER POINTE RD SW STE 140, PMB 170 OLYMPIA, WA 98502
Site Address: 3831 W FISH HATCHERY RD
Primary Parcel Number: 619113200020
Permit Description: Replace pump tank
Permit Submitted Date: 04/27/2023
Permit Issued Date: 05/02/2023
Issued By: Rhonda Thompson
Current Permit Fees Paid: $255.00 (additional fees may be requ red upon installation of system).
Permit Expiration Date: 04/28/2024 (based on date of inspection)
Type of Work OSS Repair
Components being Replaced: Pump Tank Only
Surfacing Sewage? No Existing Failure? No
Shoreline? No Horizontal Setbacks Met? Yes
Number of Bedrooms: 4 Drinking Water Source: Private Well/Spring
Additional Details: Sound Placement 1200 gallon cement
Permit Conditions:
3 Mason County Asbuilt Form, Record Drawing, and Installation fee must be submitted for
final installation approval.
4 Proposed development subject to zoning requirements and approval by the planning
department staff per Mason County Title 17.
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
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.
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OFFICIAL USE ONLY
DATE RECEIVED: ktub�� .
MASON COUNTY
FIT COMMUNITY SERVICES AM . Ems. ` RECEIVE. CO„I,
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Public Health(Community H7.Ot.4EnvironmentalHealth) G
415 N.6th Street
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415 N.6th Street-Shelton,WA 98584
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ON-SITE SEWAGE TANK ONLY APPLICATION z D
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APPLICANI PHONE I
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MAILING ADDRESS-STREET,REET,CITY,STATE.ZIP CODE oAck O c\A co
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SITE ADDRESS-STREET,CITY.ZIP CODE 73C\\W-,- C/ 1 i6V-- 985 yi cir-v\c_._..\ _4_ r-c:)44-1%-\S &) ao - e 0 .1-k I
NAME OF DESIGNER PHONE (—
NAME OF INSTALLER PHONE a P
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TYPE OF V ORK(select one) DRINKING WATER SOURCE O
❑ NEW CONSTRUCTION/UPGRADES 'EPAIR/REPLACEMENT PRIVATE INDIVIDUAL WELL ❑ PRIVATE TWO-PARTY WELL Z I--
COMPONENT(S)TO BE REPLACED/INSTALLED 0 PUBLIC WATER SYSTEM t
❑ SEPTIC TANK PUMP TANK ❑RV HOLDING TANK BEDROOMS /` LOT SIZE �
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El /OTHER y 8 C C I'CJ� W I N
OTHER DETAILS(select all that apply) TANK(S)SETBACK CHECKLIST 1- 7
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El SURFACING SEWAGE XISTING FAILURE 0 SHORELINE El 100FT+PUBLIC!COMMUNITY WELLS 0I�
SUBMITTALS 5K50FT+PRIVATE WELLS.SURFACE WATERS.STREAMS,RIVERS
❑ PLOT PLAN(REQUIRED) ❑ TANK CROSS SECTION(REQUIRED) ❑ 10FT+DRINKING WATER SUPPLY LINES IC>
❑ PUMP DETAILS(IF APPLICABLE) 0 WAIVER(S)(IF APPLICABLE) 0 5FT+PROPERTY/EASEMENT LINES,FOUNDATIONS,FOOTINGS l((����
PLOT PLAN CHECKLIST r ID'
PROPERTY LINES AND EASEMENTS XISTING/PROPOSED STRUCTURES EXISTING/PROPOSED OSS COMPONENTS AND LINES —I
-WELLS WITHIN 100FT WATER SU PLY LINES-"B DRIVEWAYS/PARKING AA SURFACE WATERS,STREAMS.RIVERS,ETC.., I N
j DIRECTION OF SLOPE/CONTOURS ❑ PERIMETER/CURTAIN DRAINS VZ,NORTH ARROW 1 SCALE BAR I
DIRECTIONS TO SITE AND SITE CONDITIONS:(ex.locked gate) �� OG \ ( ,. '-�� C)
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OFFICIAL USE ONLY BELOW THIS LINE
UPGRADE/FAILURE SOURCE(for reporting purposes)
❑VOLUNTARY 0 MAINTENANCE/PUMPING ❑BUILDING PERMIT ❑HOME SALE ['COMP jjr (�7I i .. r
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COMMENTS/CONDITIONS 11
'u!I APR 2 7 2023
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SEWAGE TANKS MUST BE LISTED UNDER DOH"LIST OF REGISTERED SEWAGE TANKS'. TANKS MUST MEET CURRENL,
IINONY3tZE REQUti Ee UIPPED 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
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THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE REVISED 7/9/2019
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OVED
APR 28 2023
MASON COUNry E •
NVIRONMENTAL HEALTH
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APPROVED
APR 2 8 2023
Ma �n Caun,y Dept. Health Services
MASON COUNTY ENVIRONMENTAL HEALT ,
RET InitialsAPPROVED
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Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT! PERMIT INFORMATION
Permit Number SWG 2—O - Parcel # tag 1 I._ .. r-_.(1-,7_
Applicant Name t t -t-- Subdivision (Name/Div/Block/Lot)
Applicant Address..5c6 11.1.).it . ' d
City, State, Zip Ft y'YIR tL1 '4 q$c,-j4 1 Installer Name 4 kO 'Q(if'LLf
Site Address `3 a). F1. 1 _ 'ids)Designer Name
INSTALLATION CHECKLIST
❑ Full System Installation 9 \k(s)Only ❑ Drainfield Only ❑ Repair 5L Other l qn k. r .P jec.0rt4 (-\ „-'
System Type tivv)un 0 Pretreatment Type
>5 ft. from foundation? - - N/A ❑ YES ❑ NO
>50 ft.from wells? - -- ❑ ❑
Z >50 ft. from surface water? - - ❑ ❑
ct Cleanout between building and tank? - - ❑ ❑
V Tank baffles present? - - ❑ ❑
a24" access risers over each compartment? - - CI CD
W Effluent filter installed?- •- ❑ ❑
CO
Septic tank capacity (working) gal Manufacturer
CI D-box water level and speed levelers used? - - 1 N/A ❑ YES ❑ NO
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O Manifold/D-box accessible from surface?- - ❑ ❑
aPE Check valves installed? - - ❑ ❑
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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
>100 ft. from wells?- - ❑ ❑
W >100 ft. from surface water? - - ❑ ❑
LT >10 ft. from potable water lines?- - ❑ ❑
Z > 5 ft. from property lines and easements?- - El ID
12 > 30 ft.from downgradient curtain/foundation drains? - - ❑ ❑
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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
YES El NO
Z Pump tank capacity (flood) I J.N7 gal Manufacturer _Tic, /f(A fed lOrd
< 24" access riser(s) and accessible from surface?- - ❑ 14 ❑
~ Alarm or Control Panel Installed? - - ® ❑ ❑
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E Control Panel equipped with Timer/ ETM/Counter- - ❑ ❑
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O. Pump installed in ❑ Bucket or ® On Block or ❑ Other
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O. Pump Make/Model (S-Z. c,wIc J 4 Floats or ❑ Transducer
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a Tank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
Upda:cd B1212018
Mason County OSS Installation Report pg. 2 Parcel#
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - ❑ YES pi 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 8 manifold orientation 8 layout,Septic/pump tank location.North arrow,reserve drainfield,existing and proposed buildings.location or wells,waterlines,
wells,observation ports,cteanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays in rnal 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
l 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.
Signatureci Installer Date
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Printed NaMe of Signee
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public
Health:
ON4/111\if' 1/11 1 C1
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 Undated 8,21/2018
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APPROVED
rvioui 5 2023
Mason County Dept. Health ServWcoA
MASON COUNTY ENVIRONMENTAL
,4M.ENTAL HEALTH
APPROVED •
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Date 2411111
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