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HomeMy WebLinkAboutSWG2019-00504 CANCELED - SWG Inactive - 6/14/2023 111 OFFICIAL USE ONLY MASON COUNTY PUBLIC HEALTH DATE RECEIVE L3' D. (9-1.(.3, Li . › ONSITE SEWAGE SYSTEM APPLICATION AMDUNr ce/ RECEIVED BY s' J - 0415 N 6th Street,(Bldg 8) Shelton WA,98584 C w Shelton:360-427-9670 ext 400 Belfain 360.275-4467 ext 400 S A G (L^ _ O 0 VV "� z fA APPLICANT PHONE > J e-f Z pc i her 3400 —7,39- 'M4S E m MAILING ADDRESS-STREET CITY,STATE,ZIPPICODE "/a q r SITE ADDRESS-STREET,CITY,ZIP CODE / Ca rs NAME OF DESIGNER PHONE (\ I r 3 hl&n/a>/ '- ° -5G - i• -1ie7 NAME OF INSTALLER PHONE I CHECK ALL APPLICABLE ITEMS DRINKING SOURCE 0 h C AIEW CONSTRUCTION 0 RV HOLDING TANK ONLY 0 PRIVAT IVIDUAL WELL (/1 IQ ❑ REPLACEMENT SYSTEM 0�INSTALLATION PERMIT ONLY 0 PRIVATE ARTY WELL 0 I i ❑ TABLE 9 REPAIR 12 IINGLE FAMILY 0"COMMUNITY/ LIC WATER SYSTEM NJ ❑ TANK(S)ONLY ❑ COMMERCIAL SYSTEM NAM -7' ;/►1(J'c, I 4it.e3 '. ❑ UPGRADE TO EXISTING 0 OTHER: BEDROOMS LOT SIZE ❑ EXISTING FAILURE "Record Drawing required e f 2 a G7 >rf I for alllnsteUedons' J r DIRECTIONS TO SITE-BE SPECIFIC AND ADVISE OF ANY NEEDED INFORMATION FOR ACCESS(ex.locked gate) • 0 I (7 t-k J•I h w,..i- A/D POI —� / i;q hi- eJri A <f e / le-Pt o n A)4 f 44( J /of " Ch Tt 416e(i4k e br Earl- 1 e erl Lvb ?L I e'F1- 0" e. khob Rd I lc , -- Site co ! r 9kr, 5 0-I . c, IJ SITE MUST BE FLAG e • •M MAI •AD AN• ST HOLES M BE FLAGGED WITH TEST HOLE NUMBERS - I—7 •FFI USE 0,- • THIS LINE UPGRADE AILURE SOURCE . rng purposes) ❑VO NTARY ❑MAI -UMPING BUIL/ 'MIT ['HOME SALE ['COMPLAINT ['OTHER: INSPEC -SOIL LOGS COMMENTS/CONDITIONS 1. - ((�c`-,vim SOIL CODES: V=VERY G=GRAVELLY S=SAND L=LOAM Si=SILT C=CLAY E=EXTREMELY R=ROOTS INSPECTOR SIGNATURE DATE APPLICATION EXPIRATION DATE APPLICATION APPROVED BY DATE THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE REVISED 12/7/2015 IIGN FORM-PAGE ONE Assessor's Parcel Number: . 2 0 e `7 -- 5 / -- et) in .a.3 . A design will be reviewed when 3 conies of each of the following are submitted: Completed design form that has been signed and dated. v Scaled layout sketch,including all applicable items on checklist Scaled plot plan,including all applicable items on checklist. 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 2O t -GOS)9 Designer's Name: LI/M j/-1-ekif Applicant's Name: J 1iC 2. .. r,i 9� Designer's Phone Number: 3100-- 5 7-/D-[o'7 Mailing Address: ).1 Q3 11 it sAa Ave 'H gti X Designer's Address: e0 Le)Y I Lf S 3 I C id A- 1'8'5' ) `T vMwc k,- WA- le- /i Ci State Zip City State Zip '.S.,;r. N, -,_ , . _. AjoISY■■/��$N iN1UTERS... „ ,,.. :tt . YY ti�..�' 1. .�..4.�Sq.. t.•:• 'Treatment Device lialendon Biofilter 0 Sand Filter 0 Mound 0 Sand Lined Drainfield 0 Recirculating Filter,Type: 0.Aerobic Unit Make/Model 0 Disinfection Unit Make/Model Other: Drainfield Type ❑ Gravity 121ressure 0 Trench 0 Bed 0 Sub Surface Drip Septic Tank/Drainfield Specifications Laterals Number of Bedrooms ,. . Schedule/Class Daily Flow: Operating Capacity i o gpd Length ft Daily Flow:Design Flow . j gpd Diameter in Septic Tank Capacity 1 Ovc7 gal Number Receiving Soil Type(1-6) Separation ft -.— -Receiving Soil-Appl-Rate- gpd/ft.. Orifices • - Required Square Footage c/00 ft Total Number of Orifices Designed Square Footage too° ft Diameter in Percent Reduction Taken — % Spacing in Trench/Bed Width - ft Manifold Trench/Bed Length ft Schedule/Class cfp Elevation Measurements Length )'-f- ft Original Drainfield Area Slope % Diameter 1 in New Slope,If Altered % Preferred manifold configuration used? 121"Yes 0 No Depth of Excavation Up-slope in Transport Pipe from Original Grade Down-slope in Schedule/Class 90 IDesigned Vertical Separation ;;,./ + in Length R O ft Gravelless Chambers Required? 0 Yes allo 0 Optional Diameter i in Pump Required? aYes 0 No Dosing and Pump Chamber Pump/Siphon Specifications Number of doses/day Q r✓' (�I enrlo i Difference in Elevation Between Pump Shutoff and Uppermost Dose quantity ,r gal Orifice ft Chamber Capacity I coo gal Uppermost Orifice❑Higher ❑Lower than Pump Shutoff Pump controls:Please check those required. Capacity @ Total Pressure Head gpm 0-Timer QElapse Meter Invent Counter Calculated Total Pressure Head ft If Timer: Pump on 5e( 411,4./oa ,Pump off Comments A DESIGN FORM—PAGE TWO Assessor's Parcel Number: 0 0'7 -- 1 -- .O d A j_ Permit Number: SWG DESIGN CHECKLISTS Scaled Plot Plan Scaled Layout Sketch Cross-Section Sketch El'Test hole locations El Drainfield orientation and layout Reference depth from original grade: I2/Soil logs 12K Trench/bed dimensions and 1"Septic tank ["Property lines critical distances within layout pibrainfield cover ❑ Existing and proposed wells O/D-Box/Valve box locations Reference depth from original grade within 100 ft of property 13 Septic tank/pump chamber and restrictive strata: ❑ Measurements to cuts,banks,and locations 0 Laterals,trench bed,top and surface water and critical areas 0 Observation port location bottom ❑ Location and orientation of 0' Clean-out location 0 Curtain drain collector curtain drain and all absorption [Manifold placement 0 Sand augmentation components 0 Orifice placement Other cross-section detail: 1Z(Location and dimension of ❑ Lateral placement with distance 0 Observation ports/clean-outs ,primary system and reserve area to edge of bed Other Information Q Buildings ❑ Audible/visual alarm referenced Yes No d Direction of slope indicator 0 Scale of drawing shown on scale E'1 0 Design staked out Waterlines bar 0 0 Recorded Notices attached C"Roads, easements,driveways, 0 0 Waiver(s)attached parking Cl 0 Pump curve attached d North arrow and scale drawing 0 0 Evaluation of failure shown on scale bar Non-residential justification 0 0 Waste strength DESIGN APPROVAL The undersigned designer must be notified by installer at time of installation E'Yes 0 No S2ign2reofr Date 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 regulations: Environmental Health Specialist Date 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. 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