HomeMy WebLinkAboutSWG2022-00096 TANK ONLY - SWG Application / Design - 3/1/2022 "+4O PLt
, 415 N 6TH STREET,SHELTON,WA 98584
MASON COUNTY SHELTON:360-427-9670,EXT 400
x��'(►'�F 1 COMMUNITY SERVICES BELFAIR:360-275-4467,EXT 400
ELMA:360-482-5269,EXT 400
Building,Planning,Envifonmental llivlth,Community Health
,:Hy1Ya'� FAX:360-427-7787
On-Site Sewage System Tank Only Permit: SWG2022-00096
OWNER KAPPERT JACOB H & SARAH E Phone: 360-628-4802
Address: 3139 DONNELLY DR SE OLYMPIA, WA 98501
APPLICANT KAPPERT JACOB H & SARAH E Phone: 360-628-4802
Address: 3139 DONNELLY DR SE OLYMPIA, WA 98501
SEPTIC INSTALLER SAM HYATT-H2F LLC Phone: 360-999-7972
Address: 570 KAMILCHE SHORES RD SHELTON, WA 98584
SEPTIC DESIGNER Jim Hunter and Associates Phone: JIM 360-507-1265
Address: PO Box 162 OLYMPIA, WA 98507
Site Address: 4881 NE NORTH SHORE RD
Primary Parcel Number: 222115101025
Permit Description: Septic and pump tanks replacement
Permit Submitted Date: 03/01/2022
Permit Issued Date: 04/20/2022
Issued By: Luke Cencula
Current Permit Fees Paid: $240.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 04/20/2023 (based on date of inspection)
Type of Work OSS Repair
Components being Replaced: Septic and Pump Tanks
Surfacing Sewage? No Existing Failure? No
Shoreline? Yes Horizontal Setbacks Met? No
Number of Bedrooms: 3 Drinking Water Source: Public Water System
Additional Details: Septic and pump tanks
Permit Conditions:
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
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.
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: www.co.mason.wa.us/health/environmental/onsiteloss-inspection-request.php or call:
360-427-9670, extension 400.
OFFICIAL USE ONLY
, DATE RECEIVED: j 1
� ".lvii� MASON COUNTY " '( ' ��- �, D
MN COMMUNITY SERVICES E RECEIVE CO cn
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Public Health(Community Health/Enybonmental Health)
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ON-SITE SEWAGE TANK ONLY APPLICATION n
APPLIC T PHONE m m
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MAILING ADDRESS-STREET.CITY STATE.ZIP CODE g
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SITE ADDRESS-STREET.CITY,ZIP CODE
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NAME OF DE IGNER PHONE
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NAME OF INSTALLER PHONE
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TYPE OF WORK(select one) DRINKING WATER SOURCE N
❑ NEW CONSTRUCTION/UPGRADES (,REPAIR/REPLACEMENT p❑ PRIVATE INDIVIDUAL WELL 0 PRIVATE TWO-PARTY WELL Z
COMPONENTS)TO BE REPLACED/INSTALLED C�PUBLIC WATER SYSTEM 1
EPTIC TANK G UMP TANK 0 RV HOLDING TANK BEDROOMS LOT SIZE I`i',
❑ OTHER _ C—e__ e c..,.._> I_._-
OTHER DETAILS(select all real apply) TANK(S)SETBACK CHECKLIST r
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/( I
ElSURFACING SEWAGE 0 EXISTING FAILURE lik. HORELINE 100FT+PUBLIC/COMMUNITY WELLS 0
SUB1M 7iALS SOFT+PRIVATE WELLS,SURFACE WATERS,STREAMS.RIVERS
I
u-PLOT PLAN(REQUIRED) Q-TANK CROSS SECTION(REQUIRED) 10FT+DRINKING WATER SUPPLY LINES
❑ PUMP DETAILS(IF APPLICABLE) 0 WAIVER(S)(IF APPLICABLE) \SFT+PROPERTY/EASEMENT LINES.FOUNDATIONS,FOOTINGS
PLOT PLAN CHECKLIST r
0
❑ PROPERTY LINES AND EASEMENTS 0 EXISTING/PROPOSED STRUCTURES 0 EXISTING/PROPOSED OSS COMPONENTS AND LINES --I
❑ WELLS WITHIN 100FT 0 WATER SUPPLY LINES ❑ DRIVEWAYS!PARKING 0 SURFACE WATERS,STREAMS.RIVERS,ETC... I N
❑ DIRECTION OF SLOPE/CONTOURS ❑ PERIMETER/CURTAIN DRAINS 0 NORTH ARROW 0 SCALE BAR — I�
DIR`CTI2STO SITE AND SITE CONDITIONS(ex locked gale) r •' 2� �l ` c\���
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2022OFFICIAL USE ONLY BELOW THIS LINE 0r,,,, o ,
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UPGRADE I FAILURE SOURCE(ler reporting purposes) '-
❑VOLUNTARY AINTENANCE/PUMPING 0 BUILDING PERMIT 0 HOME SALE ['COMPLAINT 0 OTHER.
COMMENTS/CONDITIONS
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/ISSUEO 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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