HomeMy WebLinkAboutSWG2023-00295 - SWG Application / Design - 7/13/2023 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 Tank Only Permit: SWG2023-00295
OWNER WHITE EDWARD LESTER & SUSAN Phone:
JANE
Address: PO BOX 695 GRAPEVIEW, WA 98546
APPLICANT A ACTION GROUP UTILITIES Phone:
Address: 620 93RD AVE SE OLYMPIA, WA 98501
Site Address: 241 E Vineyard Crest Rd
Primary Parcel Number: 121087890066
Permit Description: GLendon Repair
Permit Submitted Date: 07/13/2023
Permit Issued Date: 07/27/2023
Issued By: Jeff Wilmoth
Current Permit Fees Paid: $255.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 07/13/2023 (based on date of inspection)
Type of Work OSS Repair
Components being Replaced: Other
Surfacing Sewage? No Existing Failure? Yes
Shoreline? No Horizontal Setbacks Met? Yes
Number of Bedrooms: 3 Drinking Water Source: Private Well/Spring
Additional Details:
Permit Conditions:
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.
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.
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/healthlenvironmentallonsiteloss-inspection-request.php or call:
360-427-9670, extension 400.
C1J 3 ,n? L, OFFICIAL USE ONLY `
DATE RECEIVED.
N MASON COU 0 —L— t S - (--X :3cn D
II• • COMMUNITY SERVICES AMOUNT RffE''C''EENED: G(.Y� RECEIVED BY•
3 ll C
] CD co
v co
CA
rn
• f _ Public Health(Community Health/Environmental Health) c C
360-077-3670,ext.500 or 360.2754467,cat.000 ` - I^ (/a 0
415 N.6th Street-Shelton.VA0858 S W 4 (v_ fir,, -G csact3 5 xi
z 6
ON-SITE SEWAGE TANK ONLY APPLICATION v
m
m n
m
APPACANTT PHONE
f'1C14MI1/4) 61,a,Ph CM rt,c--/e J /I✓7 366 r 4'3 -t,225Z6 z
c
MAILING ADDRESS-STREET,CITY,S TE.ZIP CODE 3
6 2 13 Lu ' c a/Lf t 44. Wsz / 03
SITE ADDRESS-STREET,CITY,ZIP CODE C
P.ei ( ram% VI Pe7 1 ces' jz-4 Ir_
NAME OF DESIGNER PHONE 0-)
NAME OF INSTALLER PHONE v
- eci-lev.. 6,t-1,4, - Eert Pikt
TYPE OF WORK(select one) DRINK WATER SOURCE O
❑ NEW CONSTRUCTION/UPGRADES REPAIR/REPLACEMENT PRIVATE INDIVIDUAL WELL El PRIVATE TWO-PARTY WELL Z I DO
COMPONENT(S)TO BE REPLACED'INSTALLED 0 PUBLIC WATER SYSTEM 1
❑ SEPTIC TANK ❑ PUMP TANK ❑RV
HOLDING TANK BEDROOMS LOT SIZE U
OTHER C i. , €ON (: 0 D 3 / 4- W ICI
OTHER DETAILS(select all that apply) TANK( ETBACK CHECKLIST 0
X l ',
CI SURFACING SEWAGE EXISTING FAILURE 0 SHORELINE ,f00FT+PUBLIC/COMMUNITY WELLS 0
SUBMITT VO1
50FT+PRIVATE WELLS,SURFACE WATERS.STREAMS,RIVERS
PLOT PLAN(REQUIRED) ANK CROSS SECTION(REQUIRED) FT+DRINKING WATER SUPPLY LINES 19
ElPUMP DETAILS(IF APPLICABLE) ❑ WAIVER(S)(IF APPLICABLE) FT+PROPERTY/EASEMENT LINES,FOUNDATIONS,FOOTINGS
r
PLOT PLA HECKLIST 0 10
EXIS
OPERTY LINES AND EASEM TS TING/PRO ED STRUCTURES EXISTING/PROPOSED OSS COMPONENTS AND LINES y�
LS WITHIN 100FT ATER SUPPLY INES DRIVEWAYS/PARKING URFACE WATER EAMS,RIVERS,ETC... 1��J`
11 DIRECTION OF SLOPE/CONTOURS PERIMETER/CURTAIN DRAINS ORTH ARROW SCALE BAR
e
DIRECTIONS TO SITE AND SITE CONDITIONS (ex.locked gate)
br/ -� ��ry `2' view tf �-"
N t
r 1�i " at
is 14 .� - dvv� giver n l yk - a" (
I y
OFFICIAL 4,,,dri
USE ONLY BELOW THIS LINE
UPGRADE I FAILURE SOURCE(tor reporting purposes)
0 VOLUNTARY 0 MAINTENANCE/PUMPING 0 BUILDING PERMIT ['HOME SALE ['COMPLAINT ❑OTHER:
COMMENTS/CONDITIONS
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 APPLICATION EXPIRATION DATE APPL TION APPROVED.ISSUED BY DATE
-,
/— 3
r.3 _ G 7.27. ..vt
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBUC VIEW ON THE MASON COUNTY WEBSFTE REVISED 12/7/2015
�/
f` VINYARD CREST RD Or,
7
3 0
o O
1 A • <• 1
G
,
< \ \, .
v
z
Z ! v Lei
��� F (f a I
rs:N '
A 1A d
N _fl
07y
7C
....._ /►` >-rn
N�o
5 -c-,
, ,______Iti.
mAv
o �\ ,
4T2
� 1023 I
MASON CD l `
NTY ENVIRONn,1EN gitALTH
JBW
1
9' WI; tAi a 2' C..: 1 <3-, 00.
rlp, 0 R rr. ;J f•11 ..1Z [HP
f i
•
A``
_ z ;cn: z a ,, i1 "
z P.a Z s 1 C' c.+ Z
.y.m . ., f a7.
v E. _ `.
_
fp .,T_ _
2
C
(-
.
1
a
--d
_11 ,� g
I ,
i
8 ( x
._1
- - ) ,!,-,
, \i\
.... ....
t` kti---
PPq0VED
_t i
_,
-ti , -•
JUL 2 / 2023
_ MASON COUNTY ENVIRONMENTAL HEALTH ' )
l '.
JBW
V o ry
z