HomeMy WebLinkAboutSWG2023-00362 TANK ONLY - SWG Application / Design - 8/29/2023 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
M. : 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: SWG2023-00362
OWNER DALEY ROBERT JOHN & ROSE ANNE Phone:
Address: P 0 BOX 268 SHELTON, WA 98584
APPLICANT DALEY ROBERT JOHN & ROSE ANNE Phone:
Address: P 0 BOX 268 SHELTON, WA 98584
SEPTIC INSTALLER TJ Goos-TJ's Excavating Phone: 360-490-0217
Address: 150 E MARISA PL SHELTON, WA 98584
Site Address: 180 N Goldeneye Dr
Primary Parcel Number: 422055102023
Permit Description: Tank Replacement
Permit Submitted Date: 08/29/2023
Permit Issued Date: 08/30/2023
Issued By: Jeff Wilmoth
Current Permit Fees Paid: $255.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 08/29/2026 (based on date of inspection)
Type of Work OSS Repair
Components being Replaced: Septic Tank Only
Surfacing Sewage? No Existing Failure? Yes
Shoreline? No Horizontal Setbacks Met? Yes
Number of Bedrooms: 2 Drinking Water Source: Public Water System
Additional Details: 1000 hagerman
Permit Conditions:
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.
2 Permit must be installed by a Mason County Certified Installer unless prior written
authorization from Mason County is obtained.
3 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: ma soncountywa.govlhealth/environmental/onsiteloss-inspection-request.php or call:
360-427-9670, extension 400.
OFFICIAL USE ONLY
DATE RECEIVED: . Zia , 1,1
MASON COUNTY
COMMUNITY SERVICES AM f .�I RECEIVE
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Public Health(Community Health/Environmental Health) O Fcn
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760 N.6th Street
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415 N.6Ih Street�ShNtor,WA 9858a
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ON-SITE SEWAGE TANK ONLY APPLICATION 3 xi
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APPLICANT PHONE r
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MAILING ADDRESS-STREET,CITY,STATE,ZIP CODE 1 1 Q (� E
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SITE ADDRESS-STREET,CITY.ZIP CODE
1 SD 1\1 GGIder\ Eye. Or li-o A5Pal w« 9 Fss�t1 t k
NAME OF DESIGNER PHONE 3 I r
NAME OF INSTALLER PHONE o IN
-f C")003 Ao 9 ) 0217 < to
TYPE OF WORK(select one) DRINKING WATER SOURCE
❑ NEW CONSTRUCTION/UPGRADES g REPAIR/REPLACEMENT ❑ PRIVATE INDIVIDUAL WELL 0 PRIVATE TWO-PARTY WELL Z IVti
IS
COMPONENT(S)TO BE REPLACED/INSTALLED PUBLIC WATER SYSTEM ` t
ASEPTIC TANK ❑ PUMP TANK ❑RV HOLDING TANK BEDROOMS Q pp LOT SIZE �o IC/>
El OTHER 2 p1'�'l W I_
OTHER DETAILS(select all that apply) TANK(S)SETBACK CHECKLIST Q
❑ SURFACING SEWAGE ♦$,EXISTING FAILURE ❑ SHORELINE ®, 100FT+PUBLIC/COMMUNITY WELLS (7
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SUBMITTALS Ei 50FT+PRIVATE WELLS,SURFACE WATERS.STREAMS.RIVERS
13 PLOT PLAN(REQUIRED) ®,TANK CROSS SECTION(REQUIRED) . 10FT+DRINKING WATER SUPPLY LINES IN INr�
❑ PUMP DETAILS(IF APPLICABLE) 0 WAIVER(S)(IF APPLICABLE) or 5FT+PROPERTY!EASEMENT LINES,FOUNDATIONS,FOOTINGS
PLOT PLAN CHECKLIST r 19
a PROPERTY LINES AND EASEMENTS a EXISTING!PROPOSED STRUCTURES gl EXISTING/PROPOSED OSS COMPONENTS AND LINES —I
13-WELLS WITHIN 100FT Oti WATER SUPPLY LINES 8 DRIVEWAYS/PARKING El SURFACE WATERS,STREAMS.RIVERS,ETC... N 10
DIRECTION OF SLOPE/CONTOURS El PERIMETER/CURTAIN DRAINS E NORTH ARROW la SCALE BARS) y��nC ICG- Sl1 \./•)
DIRECTIONS TO SITE AND SITE CONDITIONS.(ex.locked gate) N
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P P R O VE
AUG 3 0 2023
OFFICIAL USE ONLY BEL�'V1�7N1S�fVETY ENVIR(�NMFNTAL HEALTH
UPGRADE I FAILURE SOURCE(for reporting purposes)
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❑VOLUNTARY ❑MAINTENANCE/PUMPING BUILDING PERMIT HOME SALE ❑COMPLAINT OTHER: j E' ( (ram (7 - -1
COMMENTS/CONDITIONS D f f w
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AUG 2 9 2023 L
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SEWAGE TANKS MUST BE LISTED UNDER DOH"LIST OF REGISTERED SEWAGE TANKS". TANKS MUST MEET CURRENT MINIMUM SIZE Y Et:ZIPPED ItiMEMISERS
AND TO SURFACE,AND INCLUDE AN EFFLUENT FILTER(IF APPLICABLE). RECORD DRAWING AND INSTALLATION REPORT REQUIRED FOR FINAL APPROVAL.
r•- c ••T�'E DATE APPLICATION EXPIRATION DATE ATION APPROVED/ISSUED BY DATE
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�E1�r�. -CANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE Ii ,,PZI
REVISED 7/9/2019
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