HomeMy WebLinkAboutSWG2023-00481 - SWG Application / Design - 11/13/2023 MASON COUNTY 415 N 6TH STREET, SHELTON,WA 98584
SHELTON:360-427-9670, EXT 400
BELFAIR:360-275-4467, EXT 400
f Public Health & Human Services ELMA:360-482-5269, EXT 400
FAX:360-427-7787
On-Site Sewage System Permit: SWG2023-00481
APPLICANT SMITH BRIAN & DANIELLE Phone:
Address: P O BOX 187 PORT GAMBLE, WA 98364
OWNER SMITH BRIAN & DANIELLE Phone:
Address: P O BOX 187 PORT GAMBLE, WA 98364
SEPTIC DESIGNER ROD LEFT -Acme Design Phone: 360-698-8488
Address: PO Box 2954 SILVERDALE, WA 98383
Site Address: 441 NE Ranch Dr
Primary Parcel Number: 223297500050
Permit Description: 3-bedroom gravity system
Permit Submitted Date: 11/13/2023
Permit Issued Date: 11/22/2023
Issued By: David Anderson
Current Permit Fees Paid: $525.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 11/21/2026 (based on date of inspection)
Permit Conditions:
1 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 Drain field installation not to exceed designed upslope and downslope depth specified on
design form.
4 Installer is responsible for obtaining Mason County installation approval prior to backfill of
system components.
5 Installer is responsible for obtaining Septic Designer/Engineer installation approval prior to
backfill of system components.
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 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 se ONLY / \
RECEIVED-RATE
COMMUNITY SERVICES p� N��`17�
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ON-SITE SEWAGE SYSTEM APPLICATION > ox
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APPLICANTI-`
DANIELLE SMITH c
MAILING ADDRESS-STREET CITY STATE ZIP CODE - E
P.O.BOX 187 PORT GAMBLE WA 98364 Lo
Sn E ADDRESS.STREET,CITY,ZIP CODE
91 ( NE RANCH DR TAHUYA WA 98588 I N
NAME OF DESIGNER PHONE I N
ROD LEFT 360-698-8488
NAME OF NSrALLER PHONE 0 I W
< I M
-
TT'PE(m/etivne) GI p DRINKINGPI WATER SOURCE �I O
PERMIT
RESIDENTIAL O55 LJ;COMMUNITY O55 [1COMMERCIAL OSS IgqR11I PRIVATE INDIVIDUAL WELL IJIPRIVATE TWO-PARTY WELL Z coI
TYPE
OF WORK(spied one/ YJ PUBLIC WATER SYSTEM -
g NEW CONSTRUCTION IUPGRADES OREPAIR/REPLACEMENT OIHER DFTULS peleolAA lknlapRA( ❑TABLE IX REPAIR I V
SuBMIRALs pI ❑SURFACING SEWAGE 0 EXISTING FAILURE ❑SHORELINE co
DESIGN FORM(REQUIRED) SEPTIC DESIGN(REQUIRED) BEDROOMS LOI SIPE r I (P
3 o I
0
5WAIVER(S)(IF APPLICABLE) A I o
DIRECTIONS TO SITE AND SITE CONDITIONS:(ea.locks(I W
PLEASE SEE MAP I o
O
I
ICJI
SVE MUSTSE FAGGED FROM MAIN ROAD AND TEST HOLES MUST BE FLAGGED WITH TESTNOLE NUMBERS I CD
- - OFFICIAL USE ONLY BELOW THIS LINE -
OvGRADEI FAILURE SCARCE IIor reporting pwposes/
0 VOLUNTARY El MAIN IENANCEIPUMPING 0 BUILDING PERMIT 0HOME SALE [)COMPLAINT 0 OTHER:
MSPECT OR SOIL LOGS COMMENTS!CONDITIONS
7tF1' U— 48 ",bbL S
Rekett Y$ W' Tof
Till: 0— 48" .LS 10 hoibi of hole-
Tff3- 46 `o` 6 t 5 it bointiof hole.
RECORD DRAWING AND INSTALLATION REPORT
SOIL V VERY G=GRAVELLY 5=SAVD L=LOAM SA SILT C=CLAY EE EXTREMELY R=ROOTS REQUIRED FOR FINAL APPROVAL.
INSPECT° SIGNATURE DATE APPLICATION EXPIRATION DATE APPL Ai APPROVED/ISSUED BY DATE
DM/103 11 (Z( /l076 1 ' ll/ZZ/c? 7j
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE REUSED 14OI2e15
'.ESIGN FORM-PAGE ONE Assessor's Parcel Number:2 2 3 2 9 - 7 5 - 0 0 0 5 0
A design will be reviewed when 3 copies of each of the following are submitted:
Completed design form that has been signed and dated. v Scaled layout sketch,including all applicable items on checklist
v Scaled plot plan, including all applicable items on checklist. v 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: I I"X IT'
PARCEL IDENTIFICATION
Permit Number_ SWO ZOZ) 'op L(b�
p - Designer's Name: ROD LEFT
Applicant's Name: DANIELLE SMITHL.L Decigner's Phone Number_ 360-698-8488
P O.BCX 187 Designer's Address: P.O.BCX 2954
Mailing Address: -. -- - --
PORI GAMBLE WA 98364 SILVERDALE WA 98383
City State Zip City State Zip
DESIGN PARAMETERS .
Treatment Device
0 Glendon Biofiller ❑ Sand Fiker 0 Mound 0 Sand Lined Drainfield ❑Recirculating Filter,Type'_
❑Aerobic Unit Make/Model 0 Disinfection Unit Make/Model _ Other:_
Drainfleld Type
Ed Gravity 0 Pressure ❑ french 0 Bed 0 Sub Surface Drip
Septic Tank/Drainfield Specifications Laterals ) Olt
Number of Bedrooms 3 Schedule/Class t3034
Daily Flow. Operating Capacity 270 gpd Length 50 ft
Daily Flow:Design Flow 360 gpd Diameter 4 in
Septic Tank Capacity 1250 gal Number 4
Receiving Soil Type(1-6) 4 Separation 5 ft
Receiving Soil Appl.Rate .6 gpd/fta Orifices
Required Primary Area 600 ftt Total Number of Orifices NA
Designed Primary Area 600 ft2 Diameter NA in
Designed Reserve Area 600 ft Spacing NA in
Trench/Bed Width 3 ft Manifold
Trench/Bed Length 200 ft Schedule/Class NA
Elevation Measurements Length NA ft
Original Drainfield Area Slope 2 % Diameter NA in
New Slope, If Altered 2 ro Preferred manifold configuration used? O Yes 0 No
Depth of Fxcavation tDunne 10 in Transport Pipe pF
from Original Grade Dovn-slope 9 in Schedule/Class 3034
Designed Vertical Separation 36 in Length ICJ. ft
Grovellers Chambers Required? ❑ Yes V Nu 0 Optional Diameter 4 in
Pump Required" 0 Yes Ii4No Dosing and Pump Chamber
Pump/Siphon Specifications Number of doses/day NA
Difference in Elevation Between Pump Shutoff and Uppermost Dose quantity NA gal
Orifice NA ft Chamber Capacity NA gal
Uppermost Orifice O Higher 0 Lower than Pump Shutoff Pump controls-Please check those required.
Capacity C Total Pressure Head NA gpm 0Timer ❑Elapse Meter 0 Event Counter
Calculated Total Pressure Head _ - -NA it If Timer: Pump on , Pump off
Comments ' -.
t ' DESIGN FORM—PAGETWO Assessor's Parcel Number 2 2 32 9 -- 7 5 -- 0 0 0 5 0_
Permit Number: SWG
DESIGN CHECKLISTS
Scaled Plot Plan Scaled Layout Sketch Cross Section Sketch
ITest hole locations d Drainfield orientation and layout Reference depth from original grade:
RI Soil logs d Trench/bed dimensions and 56 Septic tank
V'Property lines J critical distances within layout d Drainfield cover
❑ Existing and proposed wells I� D-BorJValve box locations Reference depth from original grade
within 100 ft of property 0 Septic tank/pump chamber and restrictive strata.
VMeasurements to cuts,banks,and locations Laterals,trench bed,top and
surface water and critical areas I Observation port location bottom
❑ Location and orientation of ❑ Clean-out location 0 Curtain drain collector
curtain drain and all absorption 0 Manifold placement ❑ Sand augmentation
components ❑ Orifice placement Other Foss-section detail:
dLocation and dimension of ❑ Lateral placement with distance MC Observation ports/clean-outs
primary system and reserve area to edge of bed Other Information
dBuildings 0 Audible/visual alarm referenced yes No
Direction of slope indicator ❑ Scale of drawing shown on scale ❑ lPesign staked out
Pi Waterlines bar ❑ W Recorded Notices attached
lge Roads,easements,driveways, ❑ WWaiverfs)attached
parking 0 C;'ump curve attached
li North arrow and scale drawing 0 Evaluation of failure
shown on scale bar Non-re idential justification
El *'Waste strength
❑ t?low
DESIGN APPROVAL '
'fhe undersigned designer must be notified by costa at im f u - ton IHI/Yes 0 No
E�yua NOV I Z0Z.
Signatu of Designer 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 r lauons- _ Il /2a /1073
Environmental Health Specialist Date
CAUTION: DESIGN APPROVAL IS VALID ONLY UNDER THE FOLLOWING CONDITION:
V The design is stamped"Approved"by Mason County Public Health. ��� ��V✓ The Onsite Sewage Permit has not expired,the Permit Expiration Datc is:
✓ Drainfield site conditions have not been altered to adversely affect conditions of design approval.
Please Note: The system must be installed by a certified installer,
unless prior authorization is obtained from Mason County Public Health.
An Installation Fee is required.
This form may be scanned and available for public view on the Mason County Web site.
Updated Date: 12/7/2015
Mason County WA GIS Web Map
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