HomeMy WebLinkAboutSWG2023-00146 - SWG Application / Design - 4/21/2023 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 Permit: SWG2023-00146
APPLICANT Remy, Bryck Phone:
Address: PO Box 251 HOODSPORT, WA 98548
OWNER REMY BRYCK Phone:
Address: P 0 BOX 251 HOODSPORT, WA 98548
SEPTIC DESIGNER ANTHONY 0 DEMIERO Phone:
Address: PO BOX 1174 HOODSPORT, WA 98548-1174
SEPTIC INSTALLER REMY BRYCK Phone:
Address: P 0 BOX 251 HOODSPORT, WA 98548
Site Address: XXX N Cushman Cut Off Rd
Primary Parcel Number: 423093490110
Permit Description: 2-bedroom gravity system
Permit Submitted Date: 04/21/2023
Permit Issued Date: 05/31/2023
Issued By: David Anderson
Current Permit Fees Paid: $995.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 04/25/2026 (based on date of inspection)
Permit Conditions:
1 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.
3 Drain field installation not to exceed designed upslope and downslope depth specified on
design form.
4 Installer is responsible for obtaining Mason County installation approval prior to backfill of
system components.
5 Installer is responsible for obtaining Septic Designer/Engineer installation approval prior to
backfill of system components.
6 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 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 Gc )
• ' DATE RECEIVED:
4 ` `"4 , MASON COUNTY 1 / �, 1 J
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415 N.6th Street-Shelton,WA 98584
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ON-SITE SEWAGE SYSTEM APPLICATION D D
APPLICANT PHONE m 0
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MAILING ADDRESS-STREET,CITY,STATE,ZIP CODE l p C
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SITE ADDRESS-STREET.CITY,ZIP CODE Si" APR 2 1 2023
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NAME OF DESIGNER aQ-••,l•l, PHONE By
.`f N 1�,NAME OF INSTALLER ;\: F2f, PHONE W
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PERMIT TYPE(select one) �1w ,i} RI C
_ �• ORlldltt• ATER SOURCE Cl)_
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RESIDENTIAL OSS COMMUNITY OSS ifl; O
�tRl7IA�t �+DE ATE INDIVIDUAL WELL PRIVATE TWO-PARTY WELL Z
TYPE OF WORK(select one) ,, „^• "`t}l-t'.(-% i!
1_'.� �'Y.0 i r_1 G`="`i WATER SYSTEM
ji NEW CONSTRUCTION/UPGRADES t7 REPAIR I REPLACEMENT OTHER DETAILS(select all that apply) 0 TABLE IX REPAIR I
W
SUBMITTALS ❑ SURFACING SEWAGE ❑EXISTING FAILURE 0 SHORELINE
CO
/DESIGN FORM(REQUIRED) #SEPTIC DESIGN(REQUIRED) BEDROOMS LOT SIZE O I
IJ WAIVER(S)(IF APPLICABLE) I ss X 3 5[7 0I
DIRECTIONS TO SITE AND SITE CONDITIONS:(ex.locked gate)
Z--K • cds4gitar)- (-oJlat3 SIR 119 +o -- 9 r4_ rtorK, 77-te Rd ;S a-' , _ 90.4. r-la/-lL
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SITE MUST BE FLAGGED FROM MAIN ROAD AND TEST HOLES MUST BE FLAGGED WITH TEST HOLE NUMBERS. sr--) I O
OFFICIAL USE ONLY BELOW THIS LINE
UPGRADE!FAILURE SOURCE(for reporting purposes)
❑VOLUNTARY ❑MAINTENANCE/PUMPING ❑BUILDING PERMIT ❑HOME SALE OCOMPLAINT ❑OTHER:
INSPECTOR SOIL LOGS COMMENTS I CONDITIONS
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CU'OaCYc 3'-36 ' ki tools o f 5.6,1
floe vos Very dry 'n*cr sq., ors f nt1utCJe y
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SOIL CODES: RECORD DRAWING AND INSTALLATION REPORT
V=VERY G=GRAVELLY S=SAND L=LOAM Si=SILT C=CLAY E=EXTREMELY R=ROOTS REQUIRED FOR FINAL APPROVAL.
INSPECTOR SIGNATURE DATE APPLICATION EXPIRATION DATE APPLICATION APPROVED/ISSUED BY DATE
(//2S/?o?? v 119 ZO l6
THIS F MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE REVISED 12/7/2015
DESIGN FORM-PAGE ONE Assessor's Parcel Number:,Y 02 3 0 9 -- -- 9 D / /
A design will be reviewed when 3 copies of each of the following are submitted:
Completed design form that has been signed and dated. '1 Scaled layout sketch, including all applicable items on checklist
'' Scaled plot plan, including all applicable items on checklist. '1 Cross-section sketch, including all applicable items on checklist.
This form may be scanned and available for public view on the Mason County Web site.Maximum paper size: 11"X 17"
PARCEL IDENTIFICATION
Permit Number: SWG Designer's Name: 4, tit'. rD
Applicant's Name: 3fy(..TN R.e,-(q Designer's Phone Number: 3b0 517—5 2 I 7
Mailing Address: Pt) t 2,5 I Designer's Address: /, 6oX 11711
de-ve/ 04- UM, c f(S'Ple /(c ,f&ril ' . 9r.5 '
City v State Zip City State Zip
DESIGN PARAMETERS
Treatment Device
❑ Glendon Biofilter 0 Sand Filter 0 Mound 0 Sand Lined Drainfield 0 Recirculating Filter,Type:
❑ Aerobic Unit Make/Model 0 Disinfection Unit Make/Model Other:��'vvi i
Drainfield Type
g2 Gravity 0 Pressure lil Trench da 0 Sub Surface Drip
Septic Tank/Drainfield Specifications v�' ? Laterals
Number of Bedrooms c,2 Schedule/ - •?� 30 3 c/�T-0�l/ ��5
,;
Daily Flow: Operating Capacity o 6 /90 'g gpd Length 4 •, �S ft
Daily Flow: Design Flow //I/O gpd Dia a„rtOC'' s =O� `� in
Septic Tank Capacity(working) / Zvd data'''gal Nu i 1'''''.` ` ERo �.
Qif ro-ov-:2, '-_
Receiving Soil Type(1-6) 3 f.►P)0 Separation /Z- ft
Receiving Soil Appl. Rate /8 gpd/fe Orifices
Required Primary Area 3 00 ft2 Total Number of Orifices U
Designed Primary Area ft2 Diameter in
Designed Reserve Area 30 0 ft' - Spacing / in
Trench/Bed Width 3 ft Manifold
Trench/Bed Length 10 p ft ' Schedule/Class ,<-A de />,I3cyV
Elevation Measurements Length aJlsp""I toil• ft
Original Drainfield Area Slope ?4?,, % Diameter / in
New Slope, If Altered t ' % Preferred manifold configuration used? 0 Yes ® No
Depth of Excavation Up-slope /// in Transport Pipe
from Original Grade Doan-slope
6 in Schedule/Class 363c./
Designed Vertical Separation / " in Length '7/5— ft
Gravelless Chambers Required? ® Yes 0 No 0 Optional Diameter "/,d in
Pump Required? 0 Yes ,l'd No Dosing and Pump Chamber
Pump/Siphon Specifications Number of doses/day /
Diff. in Elevation Between Pump& Uppermost Orifice ft Dose quantity
gal
Drainfield Squirt Height/Selected Residual (head) ft Chamber Capacity(flood) . gal
Uppermost Orifice 0 HigherPumpcontrols: Please check those required.
pP 0Lower tha Pump Shutoff
Capacity @ Total Pressure Head gpm ❑Timer 0 Event Counter
Calculated Total Pressure Head ft If Timer: Pum of IZt ICI o /
Comments ,gr1 cc/y 1t1/S Al0 /7oukr'.(ule11) A-0147 Grfie ' ,
/ MAY 3 1 2023
MASON COUNTY ENVIRONMENTAL HEALTH
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.DESIGN FORM—PAGE TWO Assessor's Parcel Number: 02 3_ a -_' -- -- q 0_-/—-a
Permit Number: SWG
DESIGN CHECKLISTS
Scaled Plot Plan Scaled Layout Sketch Cross-Section Sketch
Test hole locations rif Drainfield orientation and layout Reference depth from original grade:
t Soil logs cif Trench/bed dimensions and
0 Septic tank
pr Property lines critical distances within layout Drainfield cover
Existing and proposed wells D-Box/Valve box locations Reference depth from original grade
within 100 ft of property P" Septic tank/pump chamber and restrictive strata:
9/Measurements to cuts,banks,and locations
211 Laterals, trench/bed, top and
surface water and critical areas V Observation port location bottom
Et Location and orientation of Ur Clean-out location 0 Curtain drain collector
curtain drain and all absorption CZ Manifold pl ment 0 Sand augmentation
components [a' Orifice pl m t Other cross-section detail:
CY Location and dimension of ,q:"•.p
.
primary system and reserve area lZf Lateral rr ith distance .m Observation ports/clean-outs
to edg9c*Ned.,..4 Other Information
gl Buildings ~ �2
1r Aud" •sual- ferenced Yes No
Direction of slope indicator %f Sc f how n scale WI Design staked out
El Waterlines b -S ® ' Recorded Notices attached
1: 016Roads, easements, driveways, 'L;a' �•. ''Onl NE'A." El ` Waiver(s) attached
parking
co 0:--o f-Tot ❑ RI Pump curve attached
0/North arrow and scale drawing 0 GE Evaluation of failure
shown on scale bar Non-residential justification
❑ 0 Waste strength
❑ ❑ Flow
DESIGN APPROVAL
The undersigned designer must be noti ied by igtaller at time of installation Iff Yes 0 No
Signature of Designer Date i"1 P P 7 .)
The undersigned has reviewed this design on behalf of Mason County Public Health and determined it to be in
compliance with state and local on-site- re lations: MAY 3 1 2023
57-5//zoo MASON COUNTY ENVIRONMENTAL H ALTH
Environm tal Health Specialist Date DJA
CAUTION: DESIGN APPROVAL IS VALID ONLY UNDER THE FOLLOWING CONDITION:
✓ The design is stamped"Approved"by Mason County Public Health.
✓ The Onsite Sewage Permit has not expired, the Permit Expiration Date is:
✓ Drainfield site conditions have not been altered to adversely affect conditions of design approval.
Please Note: The system must be installed by a certified installer,
unless prior authorization is obtained from Mason County Public Health.
An Installation Fee is required.
This form may be scanned and available for public view on the Mason County Web site.
Updated Date: 12/7/2015
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Mason County Astzetwor 411 D:5TH.K.T Sfie:ftun,WA 985114
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0oR Code: 91 -Undeveloped- Land Addr essl: R&V GORDON
saes: Adrirncs2t 6216 f3LACK9ERRY S'
MAI/Nunsber: C:ty.State: ANCHORAGE AK
E atus: Zip: 995022130
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