HomeMy WebLinkAboutSWG2023-00366 TANK ONLY - SWG Application / Design / As-Built - 9/1/2023 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON:360-427-9670,EXT 400
r. ``` BELFAIR:360-275-4467,EXT 400
r Public Health & Human Services ELMA:360 482-5269,EXT 400
FAX:360-427-7787
On-Site Sewage System Tank Only Permit: SWG2023-00366
OWNER PEARCY ALLEN LEROY & TERESA Phone:
Address: 680 E BALLANTRAE DR SHELTON, WA 98584
APPLICANT PEARCY ALLEN LEROY & TERESA Phone:
Address: 680 E BALLANTRAE DR SHELTON, WA 98584
SEPTIC INSTALLER THAD BAMFORD- Bamford Septic Phone: 360-790-2364
Repair
Address: 301 WALLACE KNEELAND BLVD STE 224-332 SHELTON, WA 98584
Site Address: 680 E Ballantrae Dr
Primary Parcel Number: 321275000108
Permit Description: Tank only replacement
Permit Submitted Date: 09/01/2023
Permit Issued Date: 09/12/2023
Issued By: Rhonda Thompson
Current Permit Fees Paid: $255.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 09/12/2024 (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: Hagerman 1000g
Permit Conditions:
2 Permit must be installed by a Mason County Certified Installer unless prior written
authorization from Mason County is obtained.
4 Proposed development subject to zoning requirements and approval by the planning
department staff per Mason County Title 17.
3 Mason County Asbuilt Form, Record Drawing, and Installation fee must be submitted for
final installation approval.
1 Horizontal setbacks per WAC246-272A-0210 must be maintained, unless prior approval is
obtained
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
DATE RECEIVED:
MASON COUNTY •( • c >
.„ COMMUNITY SERVICES A alb ?fill cn
C N
o rTl
Public Health(Community Health/Environmental Health) z
360-427.9670 ext.400 or 360475.4467..sC 40C
4`5 N.601 Street-Shelton.WA 98584 SWG20 O 2
z (J,
ON-SITE SEWAGE TANK ONLY APPLICATION 3 L
APP r
PHONE m M
- �C
Cate) Li4 ..- 75y7 z
c
MAILING ADDRESS-STREET.CITY,STATE.ZIP OD� 3
(0E0 C �C.1 Or 51e-1401 Jek W557 m
SITE ADDRESS-STREET,CITY,ZIP CODE
SprAgE W
d NAME OF DESIGNER PHONE `1
FY �+
8
I NAME OF INSTA ' R SiF-Wmge.,
(ONE '^
n , 7 7�'� z3&y CJ
a TYPE OF WORK(select one) DRINKING WATER SOURCE O
❑ NEW CONSTRUCTION I UPGRADES /'_REPAIR/REPLACEMENT 0 PRIVATE INDIVIDUAL WELL 0 PRIVATE TWO-PARTY WELL Z
COMPONENT(S)TO BE REPLACED/INSTALLED PUBLIC WATER SYSTEM I
11(SEPTIC TANK 0 PUMP TANK ❑ RV HOLDING TANK BEDROOMS LOT SIZE ,(\
❑ OTHER 2"13De2 � .g `+r O,
TANK(S)SETBACK CHECKLIST OTHER DETAILS(select all that apply) O
❑ SURFACING SEWAGE gEXISTING FAILURE 0 SHORELINE 100FT.PUBLIC/COMMUNITY WELLS n t
X
SUBMITTALS 50FT+PRIVATE WELLS,SURFACE WATERS,STREAMS,RIVERS 0
PLOT PLAN(REQUIRED) %TANK CROSS SECTION(REQUIRED) r.4IOFT+DRINKING WATER SUPPLY LINES 0
❑ PUMP DETAILS(IF APPLICABLE) 0 WAIVER(S)(IF APPLICABLE) 05FT+PROPERTY/EASEMENT LINES,FOUNDATIONS,FOOTINGS
PLOT PLAN CHECKLIST r
yy 0
of
Di PROPERTY LINES AND EASEMENTS EXISTING!PROPOSED STRUCTURES EXISTING!PROPOSED OSS COMPONENTS AND LINES —1
❑ WELLS WITHIN 100FT ❑WATER SUPPLY LINES fg DRIVEWAYS!PARKING 0 SURFACE WATERS,STREAMS,RIVERS,ETC... 0
❑ DIRECTION OF SLOPE!CONTOURS 0 PERIMETER/CURTAIN DRAINS WORTH ARROW %SCALE BAR
,--,
640
li DIRECTIONS TO SITE AND SITE CONDITIONS:(ex.locked gate)
� /�. Wilk 2G E acith qI 1 s&
!�•.cl� ��1*1E�.Cv 1 -
►t4 Lk,)r t L- 1000 4 If .J -TA"I ..")/E -1-‘ems"
cto jS
t
-
OFFICIAL USE ONLY BELOW THIS LINE
• UPGRADE/FAILURE SOURCE(for reporting purposes)
❑VOLUNTAR<AINTENANCE/PUMPING 0 BUILDING PERMIT ['HOME SALE ['COMPLAINT ❑OT
COMMENTS/CONDITIONS D 5 l '� vu t
•
•
. °% .0,G2, ariC -- Ank=--- 5 SEP 01 2023
By C ------
SEWAGE TANKS MUST BE LISTED UNDER DOH"UST OF REGISTERED SEWAGE TANKS". TANKS MUST MEET CURRENT MINIMUM"tE'RtF9UIREMINT4t BQUtDPFn wt rH ZISERS
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 APPLICATION APPROVED!ISSUED BY DATE
9, I (ej Z.J. ,�-„ ,ri 1 I(Z/Z
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE REVISED 12/7'2015
IIPP!iiFii!i!iI!I!!!!I! IIF:II!I1 r.
�►.d?,: ■imm
■P■■■■■■■m4^w�ip�_ e■■■■■ ■ mmarm■■gkm a■■■.
.r i■. p ■r�u�ii=►,i.-i■■■.. ■■ ■■i■■■■_muma.
■■ C mi eommao o .m- ■
.�/(T■ ■.■,fit' ����il■■■■■■■A
►��.�•��.■■■■. ■se� m ■■■�■■■�■■■■■■■■■ ■ ■■
i r
■■■■i!�i■■■■ m■iaa.i.■■■■■■■■■■■■■■■■ ■. _
::::�mi .psi; ■. ■■►�■■■■■.■■e■■.■■■. ■.■
.:uD_.■■■u■■■■■i�.■■■■■■■■■■.■■■■■ ■■■■
m.■■■■m.■■■■■■■■■■......■■■■ ■. ■ ■. ■■■■■
■■ . ..■......■.■■■►��■■■■■■■■■■■.■■■m.■■■■
■ ■■■►. ■■■■■■■■■.■o �..■ ■ e�»gym■�:r.■■■■■
■C ■■■. �■■■■■.■■e.■.;.■■■�.C.m■ mi s cam ■■■■
:::
■:.■■■■■■.■■.■■►ummu ...■m■.m.■�■■■.
ommemmumm
i■■■m�■■■\i■■■■■■■ummu►i ■■■ � im . ilYi`1il:i�{W■■■
i■■■■■■■■..■■........■■ia ■■■■■■■m ■■■■.■.
i. e■■■■■■,.■■■■■■■■■■■■\I��■■■■■■■■■■■■■■■■■
1■a.■■■■■■i1■■■.... ■.■■ ►�■■■■■■■■■■■■■■■■■■
1■■■■..■■■.....■■■mammum■■■■■■■■■■■■■■■■■■
i■ .■■■■■■■► .a..e■■■\■■■..■■■.■■■■■■■■■■■
.■■■■■■■■. E.U■■M■■.■■■,.■■■■■■MOINE.Me■■
.■■■■■■■■■ee■► ummu■al ■■memo ■■e■mmu ea®.■
w i■■■■■■■■► ■ewom■■■e■■■e■■■■■■■■■.emm
1■`4■■■■■■■■\■\ \■■■■.i\■ ■►i■■■■■PWAE� MEEE.■■
1■■■■■■■■■■■■i �1�■►\►1.■►MEME 'M■\1■■■■■`rMEMM■.■■■■
1■■.■■■■■■■■■\iiumu momme■■■.■■■■[ommlane ■■
1■■■■■■■■■■■■ 'N\1■M■!i■■■■■r11\■■■■\r■■■■.■■■■
IMMEMEMMEMMEMEMMUMMEAMEMMWMINIMMEMEMMINIMMEM
IMMEMMOMMOMMEMUNREMMAMMOMMOMMEMEMEMMIMEM
l■■■ :%N\u■■■■■EWNWEMUME ■■■.►i■■■■■■■■■■■■■■
■■■ A\1■ ■■■. ■M\\■\■■■■!_`1■■►.\1■.■■■■■■■■ ■■■
I■■■iu n`►JI/■■■■■■■\� \►\■►.Eu!: �.■��■■e ■■■■■■■■■■
1■■■■i%■■■■■■■■WWWMI■MMAA►�\■\\►.■■■■■■■■■■■■■
i■■■■i■■■■■■■■■■■..■\\.r■L..►.\1■■■.■■■■■e■■■
I■■■■■.■ ■ ■■■■■ �1oi�■\i.mr1\■ ■U■r ■■e ■■■..■■■
■■L�rJ■i■e ■■■■■ e■��i1\■ em■■■e.--��.ci■■■■■■■■■.■
1■■■■�':%■■■■■■■■■■\■►\■M .■■wR.N■■■■■■■■■■■■■
1■■■■■■■■■■■■■■■■\\►n1 NMNMEi►�ii■■■■■■e■■■■■■■■
1■■■■■■■■.■■■■■■■��il.'�%.OM■■■■■■■■■■■■■■■■■■
1■■■■■■■I�1�■■■■■■■■- ■■c'%!�AMM ■■■■■■■■■■■■■ie■
1a■■■■■r,- ■■■■■■■■E■■■■.■■Ei■■■■■■..
■■■■■N1►`'a■■■■■■■■■■■■■■■■■■■■■i■. ■■■■
1■■■■■■►1.!. :■■■.■■■■■■■■.■■■■■■■■■■E■■■■M■!■■■
ormi■mi�1��■■■■■■■■■■■■■■.■■■■!■■■ormmm■gfl■■■
IELAmma A■■■■■■■m■■■■■ e....■■■■■Gui'i■mrm■■.
immommummommmi444amommigmemmommummummomm
1■■■■■■vJ■■■■■■liliiiriliittftf1Wiriii■■■■■■■■■■..■■■■
1■■■■■■■■■■■■■.1 1EIMME .■■■■■■■■■■■■■■■■■
1IMMO■■.■■.■..■'■a■..■.u...■a..na■e.a....■aa■a
1 —
I
n,K- - -. � r� R" tpip=°j,;Cgaa110t 2 / —\
2tK z. 3N . %N� Sd p ri -1 F'{ uQ' 2> = !A `40 ?
^Wii° N 7° f,° �6 O (P i° t + /,
mR ryq�* ,41V ? "' ;R ' ; : Z VA M()T ; cYFi •� ' F F."-Ng 4? q, rP9 yp Ch
X F 2� F Y e,, "t m r ' . - s � ! -'I K at p QX
i o 0 iirti z 01xP £y i. a6 1
i O O6y
ryb BSci ^3:y g T. ,- 0 \ Y w o a§ a
!_!Ig ail R J ° A ~..___1 N
Y (p
tx
52 4
4• `n
c r
v a
fig`-��•�'
a➢
g 65'00 94
t I coop
i Q 7' / 55"1ittt rivc4!1 4' - ;
° q - -- F---- T ! \
— \ _._. ` r"
1,. .o.me,:rano...x.a.oce t !iny.....y.
pV 4 4 4 §
i.! c-' rya
0 Q7t+g tt�ix 17' iii ram" �rnri
C o A b> ° / .. / '' 1 - 3
g�`� gyp � ,� I I ? - i _ - \ .
hiµ; 6: • ��✓l '
<E. � >
i c.=
r w BL L�*._. • r ai
. �n s • — g5s
n„ .?49
4R o Z �v M, / y
' iTl�I,Er7 Yw
1
jr4ON ,
" D �ca $ •
iov I gp.SoF
T.B° ;4 non.p x„9. croEA
�<�'�n�� �<� � SF.� fi� r�Z'Sp spT �� �v�n^ 5i�n�c �
T ,ZSI t N' D O� r_I a� ~� aZ T.ttg
ra o � ^114,k VED
-,e33 'g �' �� SEP 12;- or � 2023
° § `'y�F ' MASON COUNTY ENV�ONMENTAL
' I R HEALTH
RET
EK ENGINEERING INC. DATE: 6113/11 TAM°ETa`s•ravou
,DRAFTED BY: 1000 S, 1000 S-T, m
P.O.BOX 3097 BATTLE GROUND:WA 98604 D.R.N. 1 000 P & 1 000 P-T
PHONE: (360) 687-7668 FAX: (360) 687-7669 SCALE: A
NTS HAGERMAN PRE-CAS1
1
t
a ,
c.
< , c,, r till'
r_____,
iii
1 1 C >
t ±i ' ' li •i A j ■ a y J =
P11
7 ---- ----..-4 s P !� ■ ■ / 1 0 y; U I
a ==r= ° e ■ a e ■ iy I {
Y . aaa=ns� R r..r -q.A 4i -r�y.r..4
A a ■ tl 4 i E 1 I
y Y \ II g X 1 f
Pt , e N u n • A
o x .m n •
1 �a. . .c a rr
y. A n al
g ! e N ■ g t
1 IS
p a. I
i9
r I01 3
'as/t " l a i' a °Z ,
zs % s �
§;� {
1511 a p
i Q . k "Q �.y rJI a m o ,t y:
•
y ti^�
LIE;
V i sgg o _ _'L j
O n g s .. FFh' "1 Q ^
i ;41:5, "Xi,'-' Yi. - ; '''. ''' '‹ ' 'i § '''' ''',: Ar 8
f -' t 1- i<
1 "' ;q a
w
8 �•
fi R' C`
A
l'E
p I { n 'il VE D
i e � ,v =r R
.. e u v I�1; eE
-----; �!� �,Z 7 SEP 12 20
' ■ x ■ 3
° i ,, MASON OUNTYEhV1RONh�
it—
�, � a== ___ _ ' � - NTAL HEALTH
1 t -i4 _� tf
s n It�;r --�_— -- __ RET
1 p
Y I
Y -
d L
EK ENGINEERING INC. DATE: 6„3,11
TANK GCNS RtR 0e:4.RE 13APt 31E01.NE FOR•• uELs U
DRAFTED BY: 1000 S, 1000 S-T,
P.O.BOX 3097 BATTLE GROUND,WA96604 D.R.N. 1000 P & 1000 P-T
PHONE: (360) 687-7668 FAX: (360) 687-7669 SCALE:
NTS HAGERMAN PRECAST
Y1
Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG ?-0Z3 f v O 3(0 G-/ Parcel # 32.127 - 5-'o —COI 08
Applicant Name Thr€S.* P60-12eL Subdivision (Name/Div/Block/Lot)
Applicant Address (430 c bl1 f 1-3,34r(7 0-_
City, State, Zip Sid j alb ieSA-1 Installer Name --BAm -420 5 c�` ? ��
Site Address 54-''-C. Designer Name
INSTALLATION CHECKLIST
❑ Full System Installation [ Tank(s)Only ❑ Drainfield Only ❑ Repair ❑Other
System Type 6- vtrY Pretreatment Type '`—
>5 ft. from foundation? - - ❑ N/A IX YES ❑ NO
>50 ft. from wells? - - ❑ 12c ❑
Z >50 ft. from surface water? - - ElM ❑
HCleanout between building and tank? - - El NI
U Tank baffles present? - - ❑ sN ❑
a24" access risers over each compartment?- - ❑ ❑
W Effluent filter installed?- - ❑ g ❑
N c OO i el -�4�O1 T�•&- - psi
Septic tank capacity (working) � gal Manufacturer
CI D-box water level and speed levelers used? - - /A ❑ YES ❑ NO
J
oO Manifold/D-box accessible from surface?- - ❑ ❑ ❑
m- Check valves installed? - - ❑ El
oa I. " 303‘I
Bedrooms installed (check one) (4 2 ❑ 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- - ❑ NSA , YES ❑ NO
0 >100 ft. from wells?- - ❑ �g ❑
w >100 ft. from surface water? - - ❑ ill ❑
a--. >10 ft. from potable water lines?- - ❑ N ❑
Z > 5 ft. from property lines and easements?- - ❑ Ni ❑
a ❑ r ❑
� > 30 ft. from downgradient curtain/foundation drains? • -
CD
Drainfield level and observation ports present - - ❑ ❑
❑ Graveless chambers or S,Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ �z ❑
Pump tank setbacks consistent with septic tank? - - / N/A ❑ YES ❑ NO
• Pump tank capacity (flood) gal Manufacturer
4 24" access riser(s) and accessible from surface?- - ❑ ❑ ❑
F-
a Alarm or Control Panel Installed? - - ❑ ❑ ❑
E Control Panel equipped with Timer/ ETM /Counter- - ❑ ❑ ❑
D
O. Pump installed in ❑ Bucket or ❑ On Block or ❑ Other
n'• Pump Make/Model ❑ Floats or ❑ Transducer
a
Tank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
Mason County OSS Installation Report pg. 2 Parcel # 11a-7wso -CO 1c7F
ABANDONMENT RECORD
Were existing septic components abandoned
_,a1s part of this pro ect? - - YYES NO
If yes, please describe: p n rw 4( -
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - YES NO
RECORD DRAWING
This Is a permanent record and must be accurate and descriptive enough to re-locate in the need of maintenance activities and future development. Typical Hucvd
Drawings contain. Dratnfield&manifold orientation&layout.Septic/pump lank location,North arrow,reserve dramfield.existing and proposed buildings.location of wells,waterlines.
wells.observation ports.cleanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays in final installation approval and related permits.
Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER! ENGINEER
I certify that I installed the system in accordance with I certify that the system has been installed in accor-
the septic design stamped "APPROVED"by Mason dance with the septic design stamped"APPROVED"by
County Public Health and that any deviations shown Mason County Public Health and that any deviations
here have been cleared/approved by both the designer shown here have been cleared/approved by both
and Mason County Public Health and meet all State myself and Mason County Public Health and meet all
and Mason County Codes. State and Mason County Codes
I further certify that all information contained on this I further certify that all information contained on this
form and atta ed Record Drawing is accurate. form and attached Record Drawing is accurate.
9 IA ja__
Signature of Installer Dote
/,
Printed Name of Signee
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public
Health:
s i3(2 :S
Signature of Environm tal Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 8)21/201p
•
I
! t r I.
L
s `
,- H _
/ —
I c A
t
_ i---
I
!! I h±L±-1 ---I--
I • I. _ ' _ \_ ' ;- t-
1 '
_i._...1.___i......_. .__I_._ ...1,.._L_..l._.1___i._4__1,__4__.,__ ._.,.': ._i___:. .,......,_... __;______! ;___,......_ _;._._*: '
.,, ; : ; .1,_ ; 11 -\ 11 , 11 , ; , 1 , 1 , , . 1 IMP 12 ZD�3 _
, , } ,
.�- _I. MASON COUa��EN ` t�TAt, TH•
1 1•----11-- ._ .f.__-.�-,---!--^�-- -i . .--. _ . S _ _
1 ..-�.-}- + -1,-. I � ,_._I i i__.-1 j -
i ,
,
jHill !
4---L—',- ' . [ 1 t—i--1 trim' —1 11. _1.j
.....1_—0 III War' ••,,_ ..L; 1_4 1 _i I : i --7-,1 i , :., il : 1 . ,
i r.
t--. i
. -__;____+1 ___.p....]A._ mit .1..._......oreitq___. ....,....
! i " 1
1 Ir_i___L_
-I I I I 1 I_ . • , 1) NO
► i 1f
23 I I t 1 t-I
_ --I --1 LI -4
i I I I i_ .I I_ t • i --i
! !...._ ____F i il i •
1 1 I j ' \ : '� �,► !1.401 1
! !
i I 1 1 I j
- !- I- _. -: I I I , .i_1.___;__- _+__ -
-I--i _I 1_ .�—.—I_ _I_-�1 I. !- 1_ !- - �- -l
•
! 1-
f- • - 1 L RE -_,• 1- -+
I i ; -i —B�iNIFORD SE IC PAIR,(IC 1 , , ;
_#— t - _1.___i_ 1 1 I I- i-� CE kNEEI ANI OL-1iD-------r-__I —I-—1--1__-., -- _'
1_—I I I I ! I 1'I i i 332i ! -—I-- j 1 j t 1 i I
1 I' I I 1 �I I I 1 I s H TpN;wP 9R584.2985 ! 1 ! ! I ! — i i l--+ _
I !_ ___:._ i III ! a � 1;__. ._— -__— _ Ii- _ ` I 1 I ' !, ;.
I 1
I
1 ! I ! I I
i