HomeMy WebLinkAboutSWG2023-00235 - SWG Application / Design - 6/9/2023 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON:360-427-9670,EXT 400
BELFAIR:360-275-4467,EXT 400
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- 4:`/ Public Health & Human Services ELMA:360-482-5269, EXT400
FAX:360-427-7787
On-Site Sewage System Tank Only Permit: SWG2023-00235
OWNER HOWARD REVOCABLE TRUST Phone: 253.606.6473
RICHARD & DEBRAH
Address: P 0 BOX 4069 SPANAWAY, WA 98387
APPLICANT HOWARD REVOCABLE TRUST Phone: 253.606.6473
RICHARD & DEBRAH
Address: P 0 BOX 4069 SPANAWAY, WA 98387
SEPTIC INSTALLER Shane Maples- MAPLES EXCAVATING Phone: 360-463-8474
Address: 911 SE Arcadia Road SHELTON, WA 98584
Site Address: 23570 N US HIGHWAY 101
Primary Parcel Number: 422144100040
Permit Description: Replace septic tank
Permit Submitted Date: 06/09/2023
Permit Issued Date: 06/14/2023
Issued By: Rhonda Thompson
Current Permit Fees Paid: $255.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 06/14/2024 (based on date of inspection)
Type of Work OSS Repair
Components being Replaced: Septic Tank Only
Surfacing Sewage? No Existing Failure? Yes
Shoreline? Yes Horizontal Setbacks Met? Yes
Number of Bedrooms: 2 Drinking Water Source: Public Water System
Additional Details: Roth 1000 g
Permit Conditions:
4 Proposed development subject to zoning requirements and approval by the planning
department staff per Mason County Title 17.
1 Horizontal setbacks per WAC246-272A-0210 must be maintained, unless prior approval is
obtained
3 Mason County Asbuilt Form, Record Drawing, and Installation fee 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: masoncountywa.gov/health/environmentallonsiteloss-inspection-request.php or call:
360-427-9670, extension 400.
OFFICIAL USE ONLY
re, ... DATE RECEIVED. C - Q - l3
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ON-SITE SEWAGE TANK ONLY APPLICATION x.
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APPLICANT PHONE m
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MAILING ADDRESS-STREET,CITY.STATE,ZIP CODE E
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PO Pox 4&odl Spa/CV/W(1 ,WA �[838� 73
SITE ADDRESS-STREET,CITY,ZIP CODE
23590 N . htwl Iei Koadsport1wAd854g
NAME OF DESIGNER PHONE I\3
NAME OF INSTALLER PHONE
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Mo►piC s Exco►v hng 3t-0- 4 Ii3- gm zf
TYPE OF WORK(select one) DR KING WATER SOURCE cn
❑ NEW CONSTRUCTION/UPGRADES It REPAIR/REPLACEMENT IVATE INDIVIDUAL WELL ❑ PRIVATE TWO-PARTY WELL Z
COMP NENT(S)TO BE REPLACED/INSTALLED PUBLIC WATER SYSTEM
SEPTIC TANK 0 PUMP TANK 0 RV HOLDING TANK EDROOMS LOT SIZE I
❑ OTHER P 4,10 D7 I
OTHER DETAILS(select all that apply) ) TANK(S)SETBACK CHECKLIST r
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❑ SURFACING SEWAGE �J EXISTING FAILURE CI SHORELINE 1;/100FT+PUBLIC/COMMUNITY WELLS 0 1
SUB TALS LY 50FT+PRIVATE WELLS,SURFACE WATERS,STREAMS,RIVERS
PLOT PLAN(REQUIRED) 'TANK CROSS SECTION(REQUIRED) F .
�1OFT+DRINKING WATER SUPPLY LINES11
❑ PUMP DETAILS(IF APPLICABLE) 0 WAIVER(S)(IF APPLICABLE) a 5FT+PROPERTY/EASEMENT LINES,FOUNDATIONS,FOOTINGS
PLOT PLAN CHECKLIST O
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❑ PROPERTY LINES AND EASEMENTS 0 EXISTING/PROPOSED STRUCTURES ❑EXISTING/PROPOSED OSS COMPONENTS AND LINES --I
❑ WELLS WITHIN 100FT ❑ WATER SUPPLY LINES 0 DRIVEWAYS/PARKING 0 SURFACE WATERS,STREAMS,RIVERS,ETC...
❑ DIRECTION OF SLOPE/CONTOURS ❑ PERIMETER/CURTAIN DRAINS ❑ NORTH ARROW 0 SCALE BAR I@
DIRECTIONS TO SITE AND SITE CONDITIONS:(ex.locked gale)
grown is6On failed tan K,newt D3° 9atl or Roth ceps c same Iota-Hon,
OFFICIAL USE ONLY BELOW THIS LINE
UPGRADE/FAILURE SOURCE(for reporting purposes)
❑VOLUNTARY 0 MAINTENANCE/PUMPING 0 BUILDING PERMIT ❑HOME SALE ❑COMPLAINT 0 OTHER:
COMMENTS/CONDITIONS
Cel, a_G2_ Srtio- c_ 1--cA,n tic
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 APPLICATI EXPIRATION DATE APPLICATION APPROVED/ISSUED BY DATE
/1L -2/L1 LINIti3
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE REVISED 12/7/2015
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