HomeMy WebLinkAboutSWG2022-00331 - SWG Application / Design - 6/10/2022 (2) TH STREET,SHELTON,WA 98584
MASON COUNTY 415 N 6SHE TON 3 0-427-9670,EXT 400
COMMUNITY SERVICES BELFAIR:360-275-4467,EXT 400
ELMA:360-482-5269,EXT 400
Building.Plannmy,E nvuaimenwl Hwtlh,Comnwndy Health
FAX:360-427-7787
On-Site Sewage System Tank Only Permit: SWG2022-00331
APPLICANT LEVIN ALEXANDER & MARGARITA Phone: 1.206.999.0689
Address: 11812 167TH PL NE REDMOND, WA 98052
OWNER LEVIN ALEXANDER & MARGARITA Phone: 1.206.999.0689
Address: 11812 167TH PL NE REDMOND, WA 98052
SEPTIC DESIGNER Richard Bazzell -Caliber Septic Design Phone: 360-509-7900
Address: 165 Tupleo Way POULSBO, WA 98370
Site Address: 5710 E MASON LAKE DR WEST
Primary Parcel Number: 222335100116
Permit Description: Replacement pump tank
Permit Submitted Date: 06/10/2022
Permit Issued Date: 06/16/2022
Issued By: Luke Cencula
Current Permit Fees Paid: $240.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 06/16/2023 (based on date of inspection)
Type of Work Other
Components being Replaced: Pump Tank Only
Surfacing Sewage? No Existing Failure? No
Shoreline? No Horizontal Setbacks Met? Yes
Number of Bedrooms: 1 Drinking Water Source: Private Well/Spring
Additional Details: Pump tank replacement
Permit Conditions:
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 As-built Form & Record Drawing 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: www.co.mason.wa.us/health/environmental/onsiteloss-inspection-request.php or call:
360-427-9670, extension 400.
,
OFFICIAL USE ONLY
MASON COUNTY DATE RECEIVED: . 16 . 2
-II. COMMUNITY SERVICES AMO E I r REC o Cn
m
09
Public Health(Community Health/Environmental Health) � N
360-427-9670,ext.400 or 360-275-4467,ext.400 yV
415 N.6th Street-Shelton,WA 98584 S n,G IO�� _0 513% y 2
Z di
ON-SITE SEWAGE TANK ONLY APPLICATION x-
APPLICANT PHONE rn m
Alexander & Margarita Levin 206-999-0689 Z
c
MAILING ADDRESS-STREET,CITY,STATE,ZIP CODE
11812 167th Place NE, Redmond, WA 98052 m
SITE ADDRESS-STREET,CITY,ZIP CODE xi
5710 E Mason Lake Dr W, Grapeview, WA 98546 Id
NAME OF DESIGNER PHONE
Richard Bazzell 360-509-7900
NAME OF INSTALLER PHONE 0 I
ti
.,
TYPE OF WORK(select one) DRINKING WATER SOURCE �
I IJ'�
❑ NEW CONSTRUCTION/UPGRADES 0 REPAIR/REPLACEMENT 0 PRIVATE INDIVIDUAL WELL 0 PRIVATE TWO-PARTY WELL Z IViii
COMPONENT(S)TO BE REPLACED/INSTALLED 0 PUBLIC WATER SYSTEM
El SEPTIC TANK I] PUMP TANK 0 RV HOLDING TANK BEDROOMS LOT SIZE I COI
I
❑ OTHER 1 0.47
OTHER DETAILS(select all that apply) TANK(S)SETBACK CHECKLIST r
El SURFACING SEWAGE El EXISTING FAILURE 0 SHORELINE I] 100FT+PUBLIC/COMMUNITY WELLS O 1
SUBMITTALS El 50FT+PRIVATE WELLS,SURFACE WATERS,STREAMS,RIVERS X I 0
El PLOT PLAN(REQUIRED) II TANK CROSS SECTION(REQUIRED) CI 10FT+DRINKING WATER SUPPLY LINES
® PUMP DETAILS(IF APPLICABLE) ❑ WAIVER(S)(IF APPLICABLE) 0 5FT+PROPERTY/EASEMENT LINES,FOUNDATIONS,FOOTINGS
PLOT PLAN CHECKLIST O IMI".❑� PROPERTY LINES AND EASEMENTS 0 EXISTING/PROPOSED STRUCTURES IN EXISTING/PROPOSED OSS COMPONENTS AND LINES
❑D WELLS WITHIN 100FT 0 WATER SUPPLY LINES 0 DRIVEWAYS/PARKING 0 SURFACE WATERS,STREAMS,RIVERS,ETC...
O DIRECTION OF SLOPE/CONTOURS 0 PERIMETER/CURTAIN DRAINS III NORTH ARROW IIB SCALE BAR
DIRECTIONS TO SITE AND SITE CONDITIONS:(ex.locked gate)
4 From WA-3 North turn left onto Mason-Benson Rd E, travel 2.5 miles
to E Trails Rd, continue 1 .1 miles and turn left onto E Mason Lake
Drive, travel 0.9 miles to arrive at 5710 E Mason Lake Dr W
OFFICIAL USE ONLY BELOW THIS LINE
UPGRADE/FAILURE SOURCE(for reporting purposes)
❑VOLUNTARY ❑MAINTENANCE/PUMPING olirtrirLING PERMIT ❑HOME SALE El COMPLAINT DOT
COMMENTS/CONDITIONS I J �J !t" a
JcN j ?^ JL.
.
: , iiir IL ,
SEWAGE TANKS MUST BE LISTED UNDER DOH"LIST OF REGISTERED SEWAGE TANKS'.TANKS MUST MEET CURRENT MINIMUM-51ZEt RitQUIREMO=S,EQUIPPED WIT, RISERS
AND LIDS TO SURFACE,AND INCLUDE AN EFFLUENT FILTER(IF APPLICABLE). RECORD DRAWING AND INSTALLATION REPORT REQUIRED FOR F!NALAPRCV
INSPECTOR SIGN DATE APPLICATION EXPIRATION DATE APPLICATION APPROVED!ISSUED BY DATE
3.:448.4... t V . ')o V-3 17.*.4',..r--CoVe.- 4 . I 105 710'
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBS REVISED 12/7/2015
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