HomeMy WebLinkAboutSWG96-00122 - SWG Application - 3/4/1996 ON-SITE SEWAGE SYSTEM SITE EVALUATION AND DISPOSAL PERMIT
MASON COUNTY DEPARTMENT OF HEALTH SERVICES QERMR NO. SWG7}- _
�pt S H
426 W. CEDAR/P.O. BOX 1666/SHELTON, WA 98584 Date 7 N_
PHONE (360) 427-9670 Receipt o. a y
Amount$ /. Z F
3 a
CHECK APPLICABLE ITEMS ✓ m m`
MAILING ADDRESS: DAYTIME PHONE: NEW SYSTEM q
REPAIRSYSTEM a
CITY: S TE: ZIP: MAINTENANCE REVIEW y
I SINGLE FAMILY 'g
PROPERN DD ESS: OTHER Z
SPECIFY: 3
SPEC
IFIC,DPIRECTI N FOR LOCATING SIT PRIVATE WELL $
COMMUNITY WELLIPUBUC SYSTEM
'1Y7✓n ��11 / SYSTEM C
t, NA
u SYSTEM NAME
v-{plept f-cr> J,nf� r41C e APPLICANT
NAME NGL
Nameof ` ` I MAILINGADDRESS d l
Installer Lot I deft.xft.
_ Size: N ,%s acres TEL PHONE —
Nameof um ero SIGNAT IlJ I 0 1
Designer �O Gt sO ILMSOH Bedrooms 3 X stir: I�1 PLOT
Draw aP 2 onal plotf
includ / m
I n ^^
7 Pre can hole
vinin f test
holeg VJ
m$d CC _ -G
m p F
)a dist as to Ll.1 I* 6 1 i
prop oundaies.
O CC V
7 Entry oth&.roads,,
drive
NOT NOT DRAW�r —f1O`_�
CCTEM DESIc,ALL4
t wk
OFFICIAL U E ONET6 BELOW DOUBLE LINE.
rNe 7-41L SOIL LOGS T
2-2
C3 ' L 9 SsQNDYLoa H" G -/9 SA.UOyLoq r..t Q —Z.ZG SR NOYL"
L4 ,4/g- fir/( .ff� T////
Depth from Original
Grade to Restrictive /
Layer or Water Table: In.
DESIGNER DESIGNATION SCORES MINIMUM SYSTEM REQUIREMENTS
Finding Score Designer Level: ❑One (PWo
Soil Type Y 2
Vertical Separation Se / S Septic Tank Daily
p in. Capacity: / Z60 Gal. Flow: 3 G d GPD
Slope Appl. Infilt.
Parcel Size f I y I Ac. Rate r '� GPD/FR Area F -1
Distance to Shoreline U ft.. 11 Total /7 Inspapor n Date
COMMENTS/CONDI IONS FOR APPROVAL
•All septic systems must be designed and installed by contractors certified by Mason County Department of Health Services,unless prior approval is
granted by the department,or the design is by a professional engineer.
•Septic permit approval does not imply other building site requirements(i.e.RLC,Water Adequacy)have been met.
•Any change from the specified use of the property or any site alteration affecting the system design may invalidate this permit.
This Permit expires 2 years from date of she Inspection.Denial of this permit may be appealed to the Health Officer within 10 days of denial date.
SITE REVI):W. DESIGN REVIEW:O Approved jNot Approved INSTALLATION:O Approved ❑Not Approved
BY: f iY.ILIJ. DATE:!/4,f BY: DATE: BY: DATE:
TOP: Health Dept. Copy MIDDLE: Designer's Copy BOTTOM:Applicant's Copy
s
MASON COUNTY DEPARTMENT OF HEALTH SERVICES
POST OFFICE BOX 1666
SHELTON, WA 98584
p� (360)427-9670
EAX
APPLICATION FOR RE-INSPECTION'"-' � 290 d7� D
- ON-SITE SEWAGE PROGRAM- MAR 1 9 1996
DIRECTIONS +FALTH SERVICEq
1. Complete Part 1-3 and submit to the Director of Nealth services, PO sox 1666, Shelton, WA 985f14.
2. The on-site lead will make a determination in Part 4 whether a re-inspection is justified. When a re-
insoaction is made, the findings of the secant 5wirommntal Health specialist are written in Part 5. A
final determination by the lead is recorded in Part 6.
3. Applicants are billed $R when a re-inspection is required, and are expected to pay for any necessary
laboratory costs associated with soil tests, onless prior arrangements are made with the health depart-
ment.
4. Findings and determinations of the teed may be appealed to the Mason Canty Health Officer at the ad-
dress listed above.
96 - 6i��
PART 1: REQ ST FOR RE-INSPECTION Applicant's Name: r Q&
Address°' f �iYJ Uf'"Lw
Telep*ne: f 36p 0
HeaAh Department finding being disputed by applicant:
n _ n n
Ll Anticipated depth of watertabte u soil type/application rate u Depth or presence of mWitg
n
Neu drei nfieltl area t0 evaluate lJ Other (please specify) /
PART 2: AUTHORIZATION
APPLICANT - DATE
l
H:ON-6R6\F6 AL.w Re O1/OJ/96
r
PART 3: PLOT PLAN
Use this space to draw a detailed plot plan, or attach one to this application. A detailed plot plan is one that
shows the precise location of the test hales, existing septic systems, dimensions of the property, and location of any
wells, roads, or other Wildings on the property.
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PART 4: DETERAUNATION OF LEAD
Re-inspection is justified.
n
u Re-inspection is not justified, for the following reason(s) :
On-Site Lead Date
X:ON-SITEIRE-SVAL.F Revised 03/nl/96
s
PART 5: RE-INSPECTION FINDINGS
SOIL LOGS
TEST HOLE #1 TEST HOLE #2
�^3L S.-AAAMI OAM 6 -3 -T
S4�L.aQn. "(4'�tcL i I
j I �
DESIGNER DESIGNATION SCORES �i
Depth from original grade to restrictive layer:
Parameter Finding Score
Soil Type Z
vertical Separation ZO in. 10
Slope ' % p
Parcel Size /. / SAC.
Distance to Shoreline W ft. �
Total: 19,
MINIMUM SYSTEM REQUIREMENTS
Parameter Requirement
i
Designer Level 2
Septic Tank Capacity )Z oa gal.
Daily Flow }gn gpd
Applicaition Rate ,L gpd/f22
Infiltrative Area fl o ft
OTHER COMMENTS
3/Z ;l46
Env' omen Hea h Specialist DaDaD
Lwj
PART 6: RE-INSPECTION DETERbIINATION
On-Siittee Lead DaaVe I
Pilling Amount Receipt Number
x:on-sirs�ae-evu..w Re�...a VIV19e