HomeMy WebLinkAboutSWG2024-00272 - SWG Application / Design - 6/14/2024 584
MASON COUNTY 4,6N6THELTON 0H27-970,EXT 400
SHELTON'360-2759470.EXT 400
BELFAIR:360-2]5-446],EXT 400
Public Health & Human Services ELMA.360482-5269,EXT 400
FAX 360-427-7787
On-Site Sewage System Permit: SWG2024-00272
APPLICANT MILBOURN DAVID E& MELODY Phone:
Address: PO BOX 183 HUMPTULIPS, WA 98552
OWNER MILBOURN DAVID E & MELODY Phone:
Address: PO BOX 183 HUMPTULIPS, WA 98552
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: 1072 W LAKESIDE DR
Primary Parcel Number: 519015001055
Permit Description: Repair 2bd ATU to pressure trench
Permit Submitted Date: 0611412024
Permit Issued Date: 06/20/2024
Issued By: Rhonda Thompson
Current Permit Fees Paid. $805.00 (additional fees may be required upon mstauaron or system).
Permit Expiration Date: 06/14/2027 (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 Drainfield 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 OS&
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 USE ONLY
PF.tfiECLME°
MASON COUNTY HE EMEDa m N
COMMUNITY SERVICES M°G TaELF"`a C. c m
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ON-SITE SEWAGE SYSTEM APPLICATION 3 'v
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APPucANT
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David Milbourn 360-538-2246 y a
MATIINGADDRFSS STREINTY TATE➢VCOOE Humptulips Wa 98552 F A
PO Box 183
SITE ALFRESS-STREET GTE.DIE CODE Shelton Wa 98584 I If
1072 W Lakeside Dr
NAME OF U.USED PRONE I ^
Micah Halverson 360-490-6365
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'CRIMP'PI 1 led anal DRINKING WATER SOURCE
RIF RESIDENTIALOSS 7COMMUNITYOSS P1 COMMERCIALOSS ❑ PRIVATE INDIVIDUALWELL ❑ PRIVATETW6PARTV WELL 2 I _
R PUBLIC WATER SYSTEM_
TYPE OF WORN(be/ec1v�ej
F] NEW CONSTRUCTION/UPGRADES IFt REPAIR I REPLACEMENT OTHER"WILS(IActau MelarpO [I TABLE IX REPAIR Iv1 L,
❑ SURFACING SEWAGE H EXISTING FAILURE ®SHORELINE
SUBMITTALS I O
IT(DESIGN FORM(REQUIRED) F1 SEPTIC DESIGN(REQUIRED) BEDROOMS LOim12E l� Q
1 WAIVFR(S)(IF APPLICABLE) 2 .47 Ali
D FEETIONG m SITL AND R NE CONDITIONS GG KIGILale1
Meet with Rhonda 5/30/2024
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SRE MUST GE FLAGGED FROM MAIN RDAD ANDTEST NOLES MUST RE FLAGGEDWITN TEST NOLE NUMBERS. r'
OFFICIAL USE ONLY BELOW THIS LINE
UPGRANG,Pww.E YOURCEIm.,a,Y wm 1I
[]VOLUNTARY ❑MAINTENANCETUMPING ❑BUILDINGPERMIT ❑HOMESALE ❑COMPLAINT ❑OTHER'. _
60MMENTS I CONDITIONS
(PAIL TOR SOIL LOGS
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RECORD DRAWING AND INSTALLATION REPORT
SOILGODES'
V=VERY GRAVELLY 6-SAND L=LOAM SI=81 LT O=PLAN E=E%TREMELV R=ROOTS APPLICATION
IP
INSPECTOR SIGNATURE DATE APPLICATIONE%TIONDIE APPLICATION APPROVEOI LEE Y OI`
THIS FORM MAYS SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEMSffE
REVISED I2g1001
DESIGN FORM—PAGE ONE Assessor's Parcel Number:
A design will be reviewed when 3 copies of each of the following are submitted:
•Completed design form that has been signed and dated. r Scaled layout sketch,including all applicable items on checklist
s 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 ate.Maximum a er size: 1!"X/7"
PARCELIPKNT1*WATION
`, p Designer's Name: Micah Halverson
Permit Number SWG '1' t/ gn
Applicant's Name David Milboum Designer's Phone Number: 360-490-6365
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Mailing Address:
PO Box 183 Designer's Address: PO Box 1519
Humptulips we 98552 Shelton Wa 98584
Citv State Zip city State Zip
. DZSTGNP. R5.
Treatment Device
❑Glendon Bio6lter ❑ Sand Filter ❑ Mound ❑ Sand Lined Drainfidd ❑ Recirculating Filter,Type:
IliffionobicUrit Make/Model NuWater BNBE00 Disinfection Unit MakdModcl Other:
Drainfield Type
❑ Gravity erpressure I9"Trench ❑Bed ❑ Sub Surface Drip
Septic Tank/Drainfleld Specifications Laterals
Number of Bedrooms 2 Schedule/Class 40
Daily Flow: Operating Capacity 180 gpd Length 25,22,20,33 R
Daily Flow: Design Plow 240 god Diameter 1 114 in
Septic Tank Capacity(working) BNR-600 gal Number 4
Receiving Soil Type(1-6) 3 V Separation 5 On-Center ft
Receiving Soil AppL Rate .8 gpd/ft2 Orifices
Required Primary Area 300 ft, Total Number of Orifices 26
Designed Primary Area 300 ft, Diameter 3/16 in
Designed Reserve Area No Reserve fta / Spacing 48 In
TrenchBed Width 3 ft V Manifold
Trench, ed Length 100 ft Schedule/Class 40
Elevation Measurements Length Preferred ft
Original Drainfield Area Slope 5-10
Diameter 2 in
New Slope,If Altered same /o Preferred manifold configuration used? NorYes O No
Depth of Excavation Up'siope 8-15 in Transport Pipe
from Original Grade Down-dune 6 in Schedule/Class 40
Designed Vertical Separation 12+ in Length 150 If
Gravelless Chambers Required? ❑ Yes E)No ❑ Optional Diameter 2 in
Pump Required? PI Yes ❑No Dosing and Pump Chamber
Pump/Siphon Specifications Number of doses/dav 4
Diff.in Elevation Between Pump&Uppermost Orifice 20 R Dose quantity 45 gal
Drainfield Squirt Height/ 2+Selected Residual(head) _ft Chamber Capacity(flood) 1000 gal
Uppermost Orifice Laf Higher ❑Lower than Pump Shutoff
Pump controls: Please check those required.
Capacity @ Total Pressure Head 242 gpm ErTimer /� I''� �Ela{p�se�Meter Event Counter
Calculated Total Pressure Head
37.8 ft If Timer: Pump orAP VED 6hrs
Comments JUN 2 0 2024
kASCN v13CN4E\7ALHEALTH
DESIGN FORM—PAGE TWO Assessor's Parcel Number: 5_�_ 9
Permit Number: SWG
DESIGN CHECKLISTS
Scaled Plot Plan Scaled Layout Sketch Cross-Section Sketch
11 Test hole locations la Drainfield orientation and layout Reference depth from original grade:
El Soil logs FJ Trench/bed dimensions and EI Septic tank
a Property lines critical distances within layout B Drainfield cover
0 Existing and proposed wells eI D-Box/Valve box locations Reference depth from original grade
within 100 ft of property IY Septic tank/pump chamber and restrictive strata:
H Measurements to cuts,banks,and locations B Laterals,Trench/bed,top and
surface water and critical areas IB Observation port location bottom
H Location and orientation of 12 Clean-out location ❑ Curtain drain collector
curtain drain and all absorption pf Manifold placement ❑ Sand augmentation
components IB Orifice placement Other cross-section detail:
0 Location and dimension of 19 Lateral placement with distance 19 Observation ports/clean-outs
primary system and reserve area to edge of bed Other Information
H Buildings 19 Audible/visual alarm referenced Yes No
15 Direction of slope indicator Ig Scale of drawing shown on scale Ed ❑ Design staked out
la Waterlines bar If ❑ Recorded Notices attached
19 Roads, easements,driveways, ❑ P7 Waiver(s) attached
parking Off ❑ Pump curve attached
0 North arrow and scale drawing ❑ &I Evaluation of failure
shown on scale bar Non-residential justification
❑ ❑ Waste strength
❑ ❑ Flow
DESIGN APPROVAL
The undersigned designer must be#fied by installer at time of installation E(Yes ❑ No
6 liq /zoz.4(
Signature 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 regulations:
vvu � l?-ClzM
Environmental Health Specialist Date
CAUTION: DESIGN APPROVAL IS VALID ONLY UNDER THE FOLLOWING CONDITION:
✓ The design is stamped"Approved"by Mason County Public Health. 2
✓ The Onsite Sewage Permit has not expired,the Permit Expiration Date 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
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Abbreviated Description: LOST LAKE , Lot 55 & 56, Block 1
M.Halverson Design LLC ° °`"A° David Milbourn RIPhfo 1072 W LAKESIDE DR
PO Box 1519 Shelton Wa 98584 PO Box 183 Parcel's# 51901-50-01055 (Structure)
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Owner/Mnr C'tP. �nln. stiff*�un�eea
W LAKESIDE DR
PO Box 1519 Shelton Wa 98584 PO Box 183 L arcel's # 51901-50-01055 (Structure) 5
Halversondesi nllc outlook.com HUMPTULIPS WA 98552 51901-50-01056 (Parts 00
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