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SWG2024-00102 - SWG Application / Design - 3/15/2024
MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584 SHELTON:360-427-9670,EXT 400 J BELFAIR:360-275-4467,EXT 400 Public Health & Human Services ELMA:360-482-5269,EXT 400 �J""1' -'• FAX:360-427-7787 On-Site Sewage System Tank Only Permit: SWG2024-00102 OWNER STROZYK SCOTT & STEPHANIE Phone: 1.425.590.7614 Address: 13410 SE 52ND ST BELLEVUE, WA 98006 APPLICANT STROZYK SCOTT & STEPHANIE Phone: 1.425.590.7614 Address: 13410 SE 52ND ST BELLEVUE, WA 98006 SEPTIC DESIGNER MICAH HALVERSON* Phone: 360-490-6365 Address: PO BOX 1519 SHELTON, WA 98584 SEPTIC INSTALLER JAMIE WORKMAN* Phone: 360-463-9573 Address: 120 E TIMBERLAKE DR SHELTON, WA 98584 Site Address: UNKNOWN Primary Parcel Number: 221345000005 Permit Description: Upgrade to TLB for BLD2024-00176 Permit Submitted Date: 03/15/2024 Permit Issued Date: 03/25/2024 Issued By: Rhonda Thompson Current Permit Fees Paid: $265.00 (additional fees may be required upon installation of system). Permit Expiration Date: 03/15/2027 (based on date of inspection) Type of Work OSS New Construction Components being Replaced: Other Surfacing Sewage? No Existing Failure? No Shoreline? Yes Horizontal Setbacks Met? Yes Number of Bedrooms: 3 Drinking Water Source: Public Water System Additional Details: Nuwater BNR500 + Pump tank Permit Conditions: 1 Horizontal setbacks per WAC246-272A-0210 must be maintained, unless prior approval is obtained 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. 4 Proposed development subject to zoning requirements and approval by the planning department staff per Mason County Title 17. 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/onsite/oss-inspection-request.php or call: 360-427-9670, extension 400. OFFICIAL USE ONLY MASON COUNTY DATE RECEIVED: 3 � 15 I^ - - 'M CI) D. 017 COMMUNITY SERVICES/ yl4 C cn lato 5 9 AMOUNT RECEIVED: RECENED BY: jn Public Health(Community Health/Environmental Health) 57" 360-427-9670,cat 400 o,360-275-4467.e t 400 ^ - 415 N.6th Street-Shelton,WA 98584 SWG `r.17/4 1 bak 0 0 Ol 23_. cn r O 0 N Xi Z.".- cn ON-SITE SEWAGE TANK ONLY APPLICATION f�m APPLICANT PHONE r STROZYK, SCOTT 425-590-7614 L. c MAILING ADDRESS-STREET,CITY,STATE,ZIP CODE 45 3 13410 S.E. 52nd St. Bellevue WA 98006 �( z SITE ADDRESS-STREET,CITY,ZIP CODE - , a 2533 east Pickering Road Shelton WA I- I T NAME OF DESIGNER PHONE ('' Micah Halverson 360-490-6365 NAME OF INSTALLER PHONE v Jamie Workman 360-463-9573 R I TYPE OF WORK(select one) DRINKING WATER SOURCE N ui ® NEW CONSTRUCTION/UPGRADES ❑ REPAIR/REPLACEMENT 0 PRIVATE INDIVIDUAL WELL 0 PRIVATE TWO-PARTY WELL Z I COMPONENT(S)TO BE REPLACED/INSTALLED 0 PUBLIC WATER SYSTEM ~ ❑ SEPTIC TANK ❑ PUMP TANK 0 RV HOLDING TANK BEDROOMS LOT SIZE I C11 Ill OTHER Trash/Pump Combo&BNR-500 3 .67 Ac co OTHER DETAILS(select all that apply) TANK(S)SETBACK CHECKLIST I- I (^ ElSURFACING SEWAGE 0 EXISTING FAILURE 8 SHORELINE ® 100FT+PUBLIC/COMMUNITY WELLS 0 SUBMITTALS ® 50FT+PRIVATE WELLS,SURFACE WATERS,STREAMS,RIVERS ® PLOT PLAN(REQUIRED) ®TANK CROSS SECTION(REQUIRED) ® 10FT+DRINKING WATER SUPPLY LINES ® PUMP DETAILS(IF APPLICABLE) ❑ WAIVER(S)(IF APPLICABLE) ❑ 5FT+PROPERTY/EASEMENT LINES,FOUNDATIONS,FOOTINGS PLOT PLAN CHECKLIST Q I n I@ PROPERTY LINES AND EASEMENTS ® EXISTING/PROPOSED STRUCTURES 0 EXISTING/PROPOSED OSS COMPONENTS AND LINES —I ® WELLS WITHIN 100FT 0 WATER SUPPLY LINES ® DRIVEWAYS/PARKING ID SURFACE WATERS,STREAMS,RIVERS,ETC... -1 In IV DIRECTION OF SLOPE/CONTOURS II PERIMETER/CURTAIN DRAINS III NORTH ARROW III SCALE BAR DIRECTIONS TO SITE AND SITE CONDITIONS:(ex.locked gate) W IC') From Hwy 3 turn onto E pickering Rd. Driveway is next gravel drive after E Ge.: Point Rd (9 on left. Contact Designer or owner for Gate code. e.C- . 1�Ll�ZCZC1— CO 1 7G 47,0 742' �� RFC ADD OFFICIAL USE ONLY BELOW THIS LINE— if ��`4O UPGRADE/FAILURE SOURCE(for reporting purposes) ❑VOLUNTARY 0 MAINTENANCE/PUMPING gq UILDING PERMIT ❑HOME SALE ❑COMPLAINT El OTHER: COMMENTS:CONDITIONS ✓/ rati.a, 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 DATE --..---.. ' / ( IL-7 (_- „,„u,k{i-6v\ ,-*c/2_ .f THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE REVISED 12/7/2015 I / I m • / \ CD le o m • / \ CD o a / -i \ • i 2 I— — _ — ---Y m I__ — — — — -- — — \ CD / - \ (n. . - C' Existing Easement Existing Easement 1 • = - ,o rn 1 - • o 1 7 C y I 3 a L— — I 90'+I _ —o— _ — — it. • _ N8 � I A 3 d s� 1 g I C1 N fD • o �d 1 co I •• Iii • co m N' ' m \ O / D a, \ 0 / n • -0 .N ' aj oQ \ / . 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