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HomeMy WebLinkAboutSWG2019-00504 CANCELED - SWG Inactive - 12/13/2019 l OFFICIAL USE ONLY MASON COUNTY PUBLIC HEALTH DATE RECEIVED 1dL13, t 1C co ONSITE SEWAGE SYSTEM APPLICATION AMOUNTI(ECste.c, RECEIVED BY COsc5 • Cl) 415 N 6th Street,(Bldg 8) Shelton WA,98584 < Ca Shelton:360-427-9670 ext 400 Belfalr.360-275-4467 ext 400 S WG QDLct _ o 0 Z !n APPLICANT PHONE > > 7 cyy y m• 0 NJe f-c i ►�P,r 0 — . 9- m MAILING ADDRESS-STREET,CITY,STATE,ZIP CODE r (2, 103 I-nvfiso•-1 /4/P JLII-D. of y�fiia.l (y/4 g-SL�a 3 E SITE ADDRESS-STREET,CITY,ZIP CODE . CO E D�dog i b 73 NAME OF DESIGNER PHONE (Ne J1nn 14 '/✓P' 3 0 -5O - ).�� r7�' NAME OF INSTALLER PHONE iCHECK ALL APPLICABLE ITEMS DRINKING SOURCE 0 Cr C .IEW CONSTRUCTION 0 RV HOLDING TANK ONLY ElW PRIVAT IVIDUAL ELL Ul ❑ REPLACEMENT SYSTEM 0 INSTALLATION PERMIT ONLY 0 PRIVATE ARTY WELL Z J ❑ TABLE 9 REPAIR (�INGLE FAMILY IIKCOMMUNITY LIC WATER SYSTEM " El TANK(S)ONLY 0 COMMERCIAL SYSTEM NAM 7- ;./ bii I 4L�, i hc l❑ UPGRADE TO EXISTING ❑ OTHER: BEDROOMSLOT SIZE ❑ EXISTING FAILURE `ReeordDrawingrequbed t 3 <ICfri W for ail Installations' • r DIRECTIONS TO SITE-BE SPECIFIC AND ADVISE OF ANY NEEDED INFORMATION FOR ACCESS(ex locked gate) — /-1-i h w A/o N'I, -1 r;1 hf- an A 4#e / 1 Pf'fi 0 n A 4+ ie..G� f 19Et Y bath p L 1 ef•t- on E �w - 2� ch. �; 4,6e/I ti k e .b6 E, / 1 P Q n ... s•/If e cvt f'r 9 krt", r O -I SITE MUST BE FLAG,' , •M MAI •AD AN• ST HOLES M BE FLAGGED WITH TEST HOLE NUMBERS •FFI USE O 1- • THIS LINE UPGRADE AILURE SOURCE , 'ng purposes) ❑VO NTARY ❑MAI •UMPING BUIL• -MIT ['HOME SALE ['COMPLAINT ❑OTHER: INSPEC -SOIL LOGS COMMENTS/CONDITIONS idle) bt) 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 12/72015 —.GN FORM-PAGE ONE Assessor's Parcel Number: e) v "1 -- ;'> / -- )6 n _;2 1 A design will be reviewed when 3 copies of each of the following are submitted: Completed design form that has been signed and dated. `/ 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" - ':... :: : '7. ' . ' PARCEL ID.ENTIEICATION- . ' Permit Number: SWG aO\ct -CDO LI Designer's Name: (J,M /4Pp)ri Applicant's Name: .Jer--F- ea .e i,1 er Designer's Phone Number: :31.:•&) 5(�)-/ -eL,'7 Mailing Address: J.103 f-1 rrr',sah,4-✓e -.+ Sri 2- Designer's Address: PO %O X / 5 - I e/„,...,,;a WA-- `1, 50)- i vy1w<k- ivf�- `i?-6—il CitState Zip City State Zip • "' : ' : 'DESIGNPARAMETER.S. Treatment Device 12/Glendon Biofilter ❑ Sand Filter ❑Mound 0 Sand Lined Drainfield 0 Recirculating Filter,Type: ❑Aerobic Unit Make/Model 0 Disinfection Unit Make/Model Other: � Drainfield Type ❑ Gravity C�'Pressure 0 Trench 0 Bed 0 Sub Surface Drip Septic Tank/Drainfield Specifications Laterals I Number of Bedrooms ,-.2._ Schedule/Class Daily Flow: Operating Capacity i 'n gpd Length ft Daily Flow: Design Flow .fp gpd Diameter in Septic Tank Capacity /Goa gal Number Receiving Soil Type(1-6) `. Separation ft ------- - -.-- -Receiving-Soil-Appl.-Rate-- --- --,-(,�-- gp d/- ft2 Orifices-- -- Required Square Footage c f 00 ft2 Total Number of Orifices Designed Square Footage (g e O ft2 Diameter in Percent Reduction Taken — % Spacing in Trench/Bed Width ft Manifold Trench/Bed Length ft Schedule/Class W Elevation Measurements Length I - ft Original Drainfield Area Slope % Diameter 1 in New Slope,If Altered % Preferred manifold configuration used? ❑'`Yes 0 No Depth of Excavation Up-slope in Transport Pipe from Original Grade Down-slope in Schedule/Class v.7/0 Designed Vertical Separation , -,-/ -1- in Length e(p ft Gravelless Chambers Required? 0 Yes 13'No 0 Optional Diameter 1 in Pump Required? Yes ❑No Dosing and Pump Chamber Pump/Siphon Specifications Number of doses/day e ev- 6 j e,«fo ki Difference in Elevation Between Pump Shutoff and Uppermost Dose quantity `" gal Orifice ft Chamber Capacity 1 Cc gal Uppermost Orifice 0 Higher 0 Lower than Pump Shutoff Pump controls:Please check those required. Capacity @ Total Pressure Head gpm 0—Timer 12Elapse Meter invent Counter Calculated Total Pressure Head ft If Timer: Pump on 5er 0,1,4,1 ,Pump off Comments DESIGN FORM-PAGE TWO Assessor's Parcel Number: O O'7 -- 1 -- .O Ord Permit Number: SWG DESIGN CHECKLISTS Scaled Plot Plan Scaled Layout Sketch Cross-Section Sketch C'1'Test hole locations Drainfield orientation and layout Reference depth from original grade: Q"Soil logs C'Trench/bed dimensions and E/Septic tank ig'Property lines critical distances within layout p-rainfield cover ❑ Existing and proposed wells liD-Box/Valve box locations Reference depth from original grade within 100 ft of property 3/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 13/ Clean-out location 0 Curtain drain collector curtain drain and all absorption EtrManifold placement ❑ Sand augmentation components 0 Orifice placement Other cross-section detail: IZ(Location and dimension of ❑ Lateral placement with distance ❑ Observation ports/clean-outs �rimary system and reserve area to edge of bed Other Information C3 Buildings ❑ Audible/visual alarm referenced Yes No El"Direction of slope indicator 0 Scale of drawing shown on scale E( 0 Design staked out II(Waterlines bar 0 0 Recorded Notices attached "Roads,easements,driveways, 0 0 Waiver(s)attached parking 0 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 -0—El-Flow — DESIGN APPROVAL The undersigned designer must be notified by installer at time of installation .E Yes 0 No /2- Y-iY Signature of igner 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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