HomeMy WebLinkAboutSWG2023-00330 TANK ONLY - SWG Application / Design - 8/7/2023 MASON COUNTY 415 N 6TH STREET,SHELTON, ,E 98584
SHELTON: ,S 42TON, ,EXT 400
584
BELFAIR:360-275-4467,EXT 400
Public Health & Human Services ELMA:360-482-5269,EXT400
FAX:360-427-7787
On-Site Sewage System Tank Only Permit: SWG2023-00330
OWNER EVANDER STEVE N & DIANA D Phone: 360-402-1138
Address: E 570 CLAY RD SHELTON, WA 98584
APPLICANT EVANDER STEVE N & DIANA D Phone: 360-402-1138
Address: E 570 CLAY RD SHELTON, WA 98584
SEPTIC DESIGNER Bob Paysse - Pioneer Digging Inc Phone: 360-426-1803
Address: 3083 E Mason Benson Road GRAPEVIEW, WA 98546
Site Address: 570 E Clay Rd
Primary Parcel Number: 221323300010
Permit Description: RV holding tank
Permit Submitted Date: 08/07/2023
Permit Issued Date: 09/06/2023
Issued By: Jeff Wilmoth
Current Permit Fees Paid: $255.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 08/07/2026 (based on date of inspection)
Type of Work OSS New Construction
Components being Replaced:
Surfacing Sewage? Existing Failure?
Shoreline? Horizontal Setbacks Met?
Number of Bedrooms: Drinking Water Source:
Additional Details:
Permit Conditions:
5 Installer is responsible for obtaining Septic Designer/Engineer installation approval prior to
backfill of system components.
4 Installer is responsible for obtaining Mason County installation approval prior to backfill of
system components.
2 Permit must be installed by a Mason County Certified Installer unless prior written
authorization from Mason County is obtained.
1 Proposed development subject to zoning requirements and approval by the planning
department staff per Mason County Title 17.
3 Drain field installation not to exceed designed upslope and downslope depth specified on
design form.
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/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/environmental/onsiteloss-inspection-request.php or call:
360-427-9670, extension 400.
OFFICIAL USE ONLY
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DATE RECEIVED: ( -/
MASON COUNTY �a-�
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360-417-9670,ext.400It 360-775 ext.400 S\G P /' /� ^ — /•1 /-�3' \ O
415 N.6M Street.Shelton WA 98584 ,V.,("/\/J'p•%� �/Jl V 1/`//� J�\/1
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ON-SITE SEWAGE TANK ONLY APPLICATION z � '
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DIANA EVANDER z
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MAILING ADDRESS-STREET,CITY.STATE.ZIP CODE M
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570 E CLAY ROAD - SHELTON, WA 98584 m
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T rt F.DC ESS•STREET,CITY,ZIP CODE LI V _ •-
SAME AS MAILING I tv
NAME OF DESIGNER PHONE _' I IV
ROBERT H. PAYSSE 360-426-1803
NAME OF INSTALLER PHONE I
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TYPE OF WORK(select one) DRINKING WATER SOURCE O
® NEW CONSTRUCTION/UPGRADES ❑ REPAIR/REPLACEMENT 13 PRIVATE INDIVIDUAL WELL 0 PRIVATE TWO-PARTY WELL Z I N
COMPONENT(S)TO BE REPLACED/INSTALLED 0 PUBLIC WATER SYSTEM 1
❑ SEPTIC TANK ❑ PUMP TANK ®RV HOLDING TANK BEDROOMS LOT SIZE I W
❑ OTHER RV CO
OTHER DETAttB"elect all that apply)) TANK(S)SETBACK CHECKLIST Q
Li SURFACING SEWAGE 0 EXISTING FAILURE 0 SHORELINE I] 100FT+PUBLIC/COMMUNITY WELLS n 1
SUBMITTALS
ID SOFT+PRIVATE WELLS,SURFACE WATERS,STREAMS,RIVERS I CD
I] PLOT PLAN(REQUIRED) ® TANK CROSS SECTION(REQUIRED) 9 10FT+DRINKING WATER SUPPLY LINES I O
❑ PUMP DETAILS(IF APPLICABLE) II WAIVER(S)(IF APPLICABLE) 0 5FT+PROPERTY/EASEMENT LINES,FOUNDATIONS,FOOTINGS
PLOT PLAN CHECKLIST 0 r I O
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Ll PROPERTY LINES AND EASEMENTS cm EXISTING/PROPOSED STRUCTURES ® EXISTING/PROPOSED OSS COMPONENTS AND LINES
lei WELLS WITHIN 100FT II WATER SUPPLY LINES ® DRIVEWAYS/PARKING 10 SURFACE WATERS,STREArvio,7I.'EPS ETC I '—t
III DIRECTION OF SLOPE/CONTOURS LI PERIMETER/CURTAIN DRAINS ® NORTH ARROW III SCALE BAR I I O
DIRECTIONS TO SITE AND SITE CONDITIONS (ex.locked gate)
NORTH HWY 3, RIGHT ON PICKERING ROAD. RIGHT ON PHILLIPS LAKE ROAD.
RIGHT ON CLAY ROAD. FOLLOW TO END OF ROAD AND SITE ADDRESS ON RIGHT.
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OFFICIAL USE ONLY BELOW THIS LINE
UPGRADE/FAILURE SOURCE(for reporting purposes)
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Iiv"aiNTARY ❑MAINTENANCE/PUMPING ❑BUILDING PERMIT ['HOME SALE ['COMPLAINT ❑C R` / ' I
COMMENTS/CONDITIONS t / (.1W i+ /n--,v1 �-) 5c,6-yt `i' f/
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SEWAGE TANKS MUST BE LISTED UNDER DOH-LIST OF REGISTERED SEWAGE TANKS". TANKS MUST MEET CURRENT MINIMUM E REQUIREMENTS,EQUIPPED WITH RISERS
ANn I l'T T,SURFACE,AND INCLUDE AN EFFLUENT FILTER(IF APPLICABLE). RECORD DRAWING AND INSTALLATION REPORT REQUIRED FOR FINAL APPROVAL.
INSPECTOR SIGNATURE DATE APPLICATION EXPIRATION DATE APP ATION APPROVED/ISSUED BY DATE
S'—7.72 Ct tti\i'LlitA\ ZS 2-
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE REVISED 07/09/2019
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TANKS HOLDING TANK
(50'+ FROM WATER AND WELLS)
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DRAINFIELD
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SETBACK CLAY ROAD 7•
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EXPIRES
AN ASBUILTI INSTALL SIGNOFF FEE WILL
BE CHARGED AT TIME OF INSTALLATION
PIONEER DIGGING, INC. Ll ISTOMFR: DIANA WANDER TEsr HOLE I: Tt I lip i F
0245L 032 1.
PARCEL 22132 33 00010 29+GT 32+GT
SEPTIC IC DESIGNS ADDt : 570E CLAY ROAD
3083 E MASON BENSON RD. GRAPEV1EW,W'A 98546 DESIGNER: ROBERT H.PAYS'F DOCLANM TIM M OCT A SURVEY.REFEPENCES aCLUDE AFRUC NTKAWITY PROVpED
FIATS OR SURVEYS,F ELD MEASUREhENTS MO COUNTY GIS DESPH WENDED FOR SEPTL
OFFICE 360 426 1803 TAX 360 427 2353 SCALE ._ ' PO9ES ONLY PPOPOSED CEVEEOP.ENT NAY Fig SI .ECT TO OTEP
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