HomeMy WebLinkAboutSWG2024-00068 TANK ONLY - SWG Application / Design - 2/26/2024 ,trimits r ; MASON COUN
TY
Human Services 41$N 6TH STREET,SHELT
On-Site Se SHELTON: ON, WA 98584
Sewage S BELFgIR:360-�27-9670,EXT 400
OWNER
System Tank Only perm) ELMA:360� 5269,'EXT 00
t. EXT 4
R .360-427-7787
Address. RUDER BEN Jq SwG2024"00068
G MIN p & KgTHERINEq
SEPTIC DESIGNER 425 VISTA AV
SEPTIC INSTALLER
PJI M HUNTER*AVENUE
SE TUMWATER W Phone: 360 91 _
Address:
STALLER O BOX 162 A 98501 5 3324
ess:
APPLICANT
STEVE ERSCH NPI q' WA 98507 Phone: 360.7
Address:
11265 OLYMp/ 53 1226
BARRETT BURR A' WA 98508 Phone: 36 _
0 357-4272
4043 BOARDMAN CT NW OLYMPIq Phone:
Site Address:
Primary Parcel WA 985p2
Number:
Permit PermitDescription:
423325100002
2 3251 0002 SI IIyAN RD
Permit Issued
pate:
Per ssued Date: Add
pump Issued 02/26 2 24 basin to
Current P existing system
Fees Paid:
Den Expiration D $265.Date:
00
Ype of
rnponen°s being Re 02/27/2027 (additional fees may be required upon installatfrfaciionSewage? o1 system).
ne? Other Construction
inspection)
nbef of B No uction
litional Details:drooms: No Existing Failure?
4 Horizontal SetbacksNo
Drinking Water Met?lit Conditions:
Source: Yes
ns: Pump basin
3 Mason Public Water System
n County Asbui/t Form,
2 Ana/insta/latior a
Permit must be i Pprova/ Record Drawing and/
authoauthorization nsta//ed b Installation
ation fr C a Mai n fee must be Horizontal setbacks orn Mason Count ittr
obtained acks per y s obtained.
b auneaCe�ified Installer submitted for
�'1�AC246-272q_02�� un/ess prior written
Proposed setb must be
department staffpe Mason Countbject to y requirements maintained, unless prior approval is
=RTY OWNERS ARE THIS p
'ERMIT MAY RESPONSIBLE
MUST BE
BE REVOKED IF
P FOR US ONSITE DU
STALL I F THE SITE CO ERMINING q RING INSTALL ATION APPROVAL
ET ER NS AND MARKING ALL PT ION OF
ROVgL IS RE HAVE CHANGED OSS.
�speCtip REQUIRED P APPROVED. ED SINCE PROPERTY LINE AND n visit: ►nas PRIOR TO"1"rAZA HE SITE W EASEMENT LOCATIONS.
oncountywa 9ov/he RY OR FINAL OCCUPANCY OF ANY RELATED
DESIGN
360-427-967 environmental/onsite%
0> extension ss_irls STRUCTURES.
nsion 400, pection.r
equest php or call:
OFFICIAL USE ONLY
MASON COUNTY °A LkECtME° / -0 -1-4COMMUNITY SERVICES aoti� c cn
HMORt CLNLD RECEIVED Br
a�� .� cc! cn
Public Health(CommunityHcahh/Environmental Health) 0 Cl)
- ., 360-427-9670,ext.400 or 360-275-4467,ext.400
415 M 6t,Street-Shelton.WA 98504 S W G dzosai..1 _ 0,0(..,5
o 2,
Z .
ON-SITE SEWAGE TANK ONLY APPLICATIONz TJ
APPLICANT
PHONE m m
BARRETT BURR 360 866-1456
MAILING ADDRESS-STREET.CITY,STATE,ZIP COOF
Z
C
4043 BOARDMAN CT NW, OLYMPIA, WA 98502 3 00
SITE ADDRESS-STREET,Cff Y,ZIP CODE m
5741 N LAKE CUSHMAN RD, HOODSPORT, WA 98548
NAME OF DESIGNER
PHONE
JIM HUNTER 360 753-1226
NAME OF INSTALLER
PHONE0 fj
3(40 -'7 o%-1303 Z I,
TYPE OF WORK(Selecl one) DRINKING WATER SOURCE (n
S NEW CONSTRUCTION I UPGRADES REPAIR I REPLACEMENT 0 PRIVATE INDIVIDUAL WELL ❑ PRIVATE TWO-PARTY WELL
COMPONENT(S)TO BE REPLACED/INSTALLED PUBLIC WATER SYSTEM Z I/
SEPTIC TANK El PUMP TANK ❑RV HOLDING TANK BEDROOMS (9 tid, 0 S S, LOT SIZE I LC
4
❑ OTHER 2 I'd h 0(/4' .e- V c-z
OTHER DETAILS(select all that apply) _
TANK(S)SETBACK CHECKLIST I""'
CI SURFACING SEWAGE ❑EXISTING FAILURE 0 SHORELINE 100FT+PUBLIC/COMMUNITY WELLS O t
SUBMITTALS IIIIIIf 50FT+PRIVATE WELLS,SURFACE WATERS,STREAMS,RIVERS X
MI PLOT PLAN(REQUIRED) N TANK CROSS SECTION(REQUIRED) M 10FT+DRINKING WATER SUPPLY LINES
• PUMP DETAILS(IF APPLICABLE) ❑ WAIVER(S)(IF APPLICABLE) IN 5FT+PROPERTY/EASEMENT LINES,FOUNDATIONS,FOOTINGS
PLOT PLAN CHECKLIST r Ic
al PROPERTY LINES AND EASEMENTS II EXISTING/PROPOSED STRUCTURES 1111 EXISTING/PROPOSED OSS COMPONENTS AND LINES
0 WELLS WITHIN 100FT II WATER SUPPLY LINES la DRIVEWAYS/PARKING ❑SURFACE WATERS,STREAMS,RIVERS,ETC... le'
❑ DIRECTION OF SLOPE/CONTOURS ❑PERIMETER/CURTAIN DRAINS NORTH ARROW *SCALE BAR
DIRECTIONS TO SITE AND SITE CONDITIONS:(ex.locked gate)
LEFT AT HOODSPORT TO LAKE CUSHMAN. FOLLOW TO SITE ADDRESS ON LEFT.
OFFICIAL USE ONLY BELOW THIS LINE
UPGRADE,FAILURE SOURCE(for reporting purposes)
❑VOLUNTARY ❑MAINTENANCE/PUMPING ❑BUILDING PERMIT ['HOME SALE ['COMPLAINT ['OTHER:
COMMENTS.CONDITIONSp
Pi9(nlyog9n 4D � S} S - �"` 7 ZO��
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
APPLICATION APPROVED ISSUED BY 7 DATE
/2/7 1-7 ---7 z7/
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE
REVISED 127'2015
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