HomeMy WebLinkAboutSWG2024-00077 TANK ONLY - SWG Application / Design - 2/29/2024 (�,uvwfv� �P`'1r
MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
at , 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: SWG2024-00077
OWNER WILLIAMS RANDALL T & DESIREE C Phone: 360.584.5686
Address: 1570 E GRAPEVIEW LOOP RD GRAPEVIEW, WA 98546
APPLICANT WILLIAMS RANDALL T& DESIREE C Phone: 360.584.5686
Address: 1570 E GRAPEVIEW LOOP RD GRAPEVIEW, WA 98546
SEPTIC DESIGNER JAMES MEDCALF* Phone: 360-426-9277
Address: PO BOX 1552 SHELTON, WA 98584
SEPTIC INSTALLER JAMES MEDCALF* Phone: 360-426-9277
Address: PO BOX 1552 SHELTON, WA 98584
Site Address: 1570 E GRAPEVIEW LOOP RD
Primary Parcel Number: 221132400030
Permit Description: Add pump basin for ADU
Permit Submitted Date: 02/29/2024
Permit Issued Date: 03/01/2024
Issued By: Rhonda Thompson
Current Permit Fees Paid: $265.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 03/01/2027 (based on date of inspection)
Type of Work OSS New Construction
Components being Replaced: Other
Surfacing Sewage? No Existing Failure? No
Shoreline? No Horizontal Setbacks Met? Yes
Number of Bedrooms: 4 Drinking Water Source: Private Two-Party Well
Additional Details: Pump basin
Permit Conditions:
5 Installer is responsible for obtaining Septic Designer/Engineer installation approval prior to
backfill of system components.
6 Mason County Asbuilt Form, Record Drawing, and Installation fee must be submitted for
final installation approval.
4 Installer is responsible for obtaining Mason County installation approval prior to backfill of
system components.
1 Proposed development subject to zoning requirements and approval by the planning
department staff per Mason County Title 17.
3 Drain field installation not to exceed designed upslope and downslope depth specified on
design form.
THIS PERMIT MUST BE ONSITE DURING INSTALLATION OF OSS.
PROPERTY OWNERS ARE RESPONSIBLE FOR DETERMINING AND MARKING ALL PROPERTY LINE AND EASEMENT LOCATIONS.
THIS PERMIT MAY BE REVOKED IF THE SITE CONDITIONS HAVE CHANGED SINCE THE SITE WAS INSPECTED AND/OR DESIGN
APPROVED.
FINAL INSTALLATION APPROVAL IS REQUIRED PRIOR TO TEMPORARY OR FINAL OCCUPANCY OF ANY RELATED STRUCTURES.
For Final Inspection visit: masoncountywa.gov/health/environmental/onsiteloss-inspection-request.php or call:
360-427-9670, extension 400.
OFFICIAL USE ONLY
DATE RECEIVED:
MASON COUNTY 2 ( ?- /0_14 c N
PA i. •rilt • COMMUNITY SERVICES AMOUNT RECEIVED. RECEIVEDRCO
rn
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Pubhc HealthI . , 5 °
(Community Health/Environmental Health) lii
C N
- 3670S-N 26 6 S7O0e e .40$he hao n36.6WA279854t
5867,et.400 S G Q iJ^.L , - 0t QO
Z 2 ON-SITE SEWAGE SYSTEM APPLICATION
m n
APPLICANT P.-ONE m
Randy Williams 360-580-8289 z
MAILING ADDRESS-STREET,CITY,STATE,ZIP CODE 3
1570 E Grapeview Loop Rd Grapeview Wa 98546 co
SI 1 E ADDRESS-STREET,CITY,ZIP CODE
Same as Above IN
NAME OF DESIGNER PHONE
James Medcalf 360-239-7779 IN
NAME OF INSTALLER PHONE I—
Active Underground LLC 360-426-9277 N r
PERMIT TYPE(select one) DRINKING WATER SOURCE O
lyr RESIDENTIAL OSS rl COMMUNITY OSS n COMMERCIAL OSS of PRIVATE INDIVIDUAL WELL n PRIVATE TWO-PARTY WELL Z 11)4
TYPE OF WORK(select One)
M PUBLIC WATER SYSTEM t
M NEW CONSTRUCTION/UPGRADES r7 REPAIR/REPLACEMENT OTHER DETAILS(select ell That apply) ❑ TABLE IX REPAIR I 0
SUBMITTALS 0 SURFACING SEWAGE 0 EXISTING FAILURE 0 SHORELINE W
DESIGN FORM(REQUIRED) SEPTIC DESIGN(REQUIRED) BEDROOMS LOT SIZ r I
O
5 WAIVER(S)(IF APPLICABLE) ��o,n K O�k'f ) 4 aCx� n I
DIRECTIONS TO SITE AND SITE CONDITIONS:(ex.locked gate) O
Driveway is directly off Grapeview Loop Rd and address is well marked on South side of 10
Grapeview Loop ,-
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IcAi
SITE MUST BE FLAGGED FROM MAIN ROAD AND TEST HOLES MUST BE FLAGGED WITH TEST HOLE NUMBERS. I
OFFICIAL USE ONLY BELOW THIS LINE
UPGRADE/FAILURE SOURCE(for reporting purposes)
❑VOLUNTARY 0 MAINTENANCE/PUMPING ❑BUILDING PERMIT ❑HOME SALE ❑COMPLAINT ❑OTHER:
INSPECTOR SOIL LOGS COMMENTS/CONDITIONS
•."-.)c--a k,(\\L on\ 4-6
r---
/A- D1A
RECORD DRAWING AND INSTALLATION REPORT
SOIL CODES:
V=VERY G=GRAVELLY S=SAND L=LOAM Si=SILT C=CLAY E=EXTREMELY R=ROOTS REQUIRED FOR FINAL APPROVAL.
INSPECTOR SIGNATURE DATE APPLICATION EXPIRATION DATE APPLICATION APPROVED/ISSUED BY DATE
/----------' *-3( I h'el \ --I\Q jyal St 1/2 Y
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE REVISED 12/7/2015
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MAR 01 2024
MASON COUNTY ENVIRONMENTAL HEALTH
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