HomeMy WebLinkAboutSWG2004-00320 - SWG Application / As-Built - 4/15/2005 ON-SITE SEWAGE SYSTEM PERMIT
T�
MASON COUNTY DEPARTMENT OF HEALTH SERVICES PERMIT NO. SING--- - -' N
r a o
426 V:. CEDAR/ P.O. BOX 1666/ SHELTON. WA 98584 Receipt No r [_
PHONE (360) 427-9670
Amount$ tro -i
PROPf�9TY ON/NER' DAL E
t L V) �{� �7 / CHECK APPLICABLE ITEMS pI
,n
i MAILI ADDRESS: U /DAYTIME F" NL-
� 7— � 7 �71 S L0 YzS � 7 u r`FP •T _FAIN SVSTEI
—.
CITY STATE TA 6HEPAIF
jFn 0N-,nr, `7C•�C) LG VA hr `,ANCc RE✓EW __ g
PROPERTY ADDRE S. - S E F46..ILv 7
� 7 w t cr�rr
nl.✓� Cl= t0Y ?,X.12_`__'_D _I�[�_avn�:if o H P Tpi
}SPECIFIC DIRECTIONS FOR LOGATIN SITE PII ATE WELL m
r 1 6Ai STo R.c c)F' XiSISTEV EL,pVBL csrsrEM -- --
Err`NFIs I l'
it 1� elot'f RD 1 f-A a- F0 Nc7r_CL/ tNp or SYSTEV NAME
APPLII N
" '- -VL Sd-i7DN, ✓A i�-C--z Off✓ QW-3r�i <r0 .
Nameofj . Lot Xep ft. �C ft AAILINS ADDRESS to y5?-yy-�lf- w �J
Installer �t CFi G2 0 '� LaYr:NOi �`160 -c
Name of Size- �:C>__._ acres rELE?,ONE ( �� 17-TS '7q' o
Designer? � JOU�-Tj um ero •/ SIG U E� -
Bedrooms R�
OFFICIAL USE ONLY BELOW THIS LINE o
u bd
DEPARTMENTAL SOIL LOGS DFPAHTMENTAL COMMENT&CONDITIONS wd
re
(Lai flrot
SOIL TEXTURE CODES'.
V=Very G=gravelly S=sand L=loam Si=silt C=clay E=Extremely
r
INSRECTOR(print name) IN59f=CTJON SIGNATURE DATE PERMIT XPIRATION DATE o y�
•All systems require ongoing Operation and Maintenance(O&M)as specified o Mason Cou ry On'be Standards, V
•All on site sewage systems must be designed by a Mason County Codified Designer or a Professional Engineer,unless prior approval is granted o1ielossi
•All on site sewage systems must be installed by a Mason County Codified Installer,unless prior approval is granted otherwise.In such cases a preli it ry ttere?�
meeting between health department staff and the homeowner is required.
-On site sewage system design approval does not imply other building site requirements(I.e.RLO,Water Adequacy)have been met. I N
-Any change from the specified use of the property or any site alteration electing the system design may Invalidate this permit C4
•This erm�ex lres 3 ears hom the tlate of site review.Denial of Nie arait maybe a ealed to the Health Officer within 10 dos of denial date.
DESIGN REVIEW APPROVAL BY: DATE: INSTALLATION APPROVED BY. DATE:
TOP: Health Dept. Copy MIDDLE: Designer's Copy BOTTOM: Applicant's Copy
AS-BUILT FORM RevisedFetn m B,IWS
PARCEL IDENTIFICATION
Applicant P, Ct+4Rj) �(rx�� Assessor's
20oq Parcel I � jZC�
Perml[Number SWG - L � —�3rU (TwSlvaDigk Number)
Installer JNCK 30t( M1r$pi✓ Subdivision
(Name/DiviaioNBbcklLot)
Designer �Ol_> RECF.„INFO
'INSTALLER CHECKLIST i
NIA Yes Prior to omPletion
I. SEPTICTANK
A) >5 ft.From foundation? . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. . .. . . .. .. _
B) >50 ft from wells and surface water? . . . . . . . . .. . . . . . . . . . . . . . . . . .. _
C) Bldg stub-out to septic tank:clean-out if not 1-2%? . . ... . . .. . . . . . . . . —
D) Baffles intact and clean? . . . .. . . . . . . . . . . .. . . . .. . . . . . . .. . . . . . .. .
E) Dividing wall intact?. . . . . . . . .. . . . .. . . . .. . . . . . . .. . . . . . . .. . . .. . .
F) Risers installed for access? . . . .. . .. . . . . . . . . . . . . . . . . . . . . ... .. .. .. _
G) Tank Size: gal.; Manufacture
II. D-Box
A) Leveled with water? . . . . . . . . . . . . . . . . . . .. . . . .. . . . . . . . . .. . . . . . .
B) Speed leveler used? . . .. . . . . .. . . . . . . . . . . . . . .. . . . . . . .. . .. . . .. . . —
III. DRAINFIELD
A) >10 ft from foundation and>5 ft from property lines? . . . . ... .. .. .. . —
B) >100 ft from wells and surface water? . . . . . . . . . . . . . . . . . . .. . . .. .. .
C) >10 ft from potable water lines? . .. . . . . .
D) Laterals level to±1 inch&end caps present if❑ ooped? .. ... .. .. . .
E) Graveltess chambers utilized? . .. . . . . .. . . . . . . . . . . .. . . . . . . . .. . . .
F) System dimensions the same as shown on m6 design? . . . . . . .. . . . . . . . .
G) Gravel clean,properly sized,aZpropeSpin? . . . . . .. . .. ... . .. . . . .
IL PRESSURE SYSTEMS
1) Sand quality ASTM C-33 .. . . . ... . .. . . ... . .. .. .. ..2) Headheightuniforman Actual head height_.. .
3) Clean-outs and obse lion ports present? ... . .. . ... ... .. ..... . —
4) Mound: Side SI 3:1? . .. . . . . .. . . . . ... . . . . .. . .. . ... .. . . . —
5) Owmer infomud electrical connections must be made by
owner or licensed electrician and inspected by L&I? . . . .. . .. .. . . . —
IV. PUMP/PUMP CHAMBER 610,E
A) Pump make sautJMMT� �� ;Pump model Sri-.V5-oAl,)/. �1�'ZS — /y, —
B) Chamber size him gal; Manufacture r-Rt�:O l(ly--
C) Height of pump off bottom of pump chamber 2-° inches — —
D) Pump chamber draw-down gallons per inch
E) Pump capacity h -i5 gallons per minute
F) Pump controls:Timer(or)Elapsed Time Meter (circle if installed)
If timer is used:Pump On Pump Off —
G) ®py_asketor effluent filter(circle one)installed? ..... .. ... .... .. — —>� —
H) Riser installed for access? ... . .... . . . .. . . . . ... ... . .. . .. ... . . .. .. — — —
I) Alarm installed? .. ....... ..... ............. .. . ... . ...... .. ...
Sa'>
D
AB-8U14T DRAWING,
CHECKLIST •••�' �� �-J�.(_���1�
❑ Drainfield&manifold 11'�
orientation & layout A?t,lM �
19 ,`A inON COVtiI nLt5vUk1)
Cl Trench/bed dimensions
and critical distances
within layout
❑ Septic/pump tank
placement.
❑ Location of buildings.
❑ Observation port&clean-
out location.
❑ Location ofwells&
roads.
❑ Undisturbed native soil
between trenches.
❑ North arrow
CAUTION:Mirror adjestamas in septic mole location and drvn6eld orientffifoa made in Ne field by the bundler art gmeNly acceptable m both the depamrcm
and the dml�er bmmWd'm¢stain emn wmpmmiu dse viability o[me systttn. It u the imWler's respomlbllry m oDhio Pnm wntleo appmvd from mmeme
hcdm an"..tevtor the designer betom mativg arty deviations from the design Net affect the system viability. MY deviaaom from the gipmvd design min be
shown above.
CERTIPICATtoN OF WTALLATtoN
Installer Check a box from Row"A"and"B",sign and date the certification
A. ❑ 1 certify that I installed the system without any f certify that all deviations from the design stamped
deviation from the design stamped"APPROVED"by 'WPROWD"by MCDHS are shown above.
MCDHS
B. ❑ I certify that I contacted the designer and left the ❑ I did not contact the desifier prior to final cover because dte
system open for inspection up to his prior m designer waived the notification requirement.
cover.
I further certify that all information contained on this form is accuratetLuu-derstaa d ' the information contained herein a not
accurate,there will bejust cause for immediate suspension of my ins on.
3- -b,5
re or LV=er
The undersigned approves this installation on behalf of Mason County Depament of jeal Services.
�Csz 4 b�ff
farm ate
t
P�nw� r SW G -4 J -ova z-o
LDS {3u r I-r PV M (� s ySlz'M -ro
tl isl4NG LOP-ncsys-IEM
z,
E ,EIVED
e MAR 1 i 2065
'MAR t 1)206":r
N
u
0
U n
o
`� � 313eoRoon
I
I�
i � ni e
o0?
r--u ree 3<'-*n c
C7LfTL.6T� t l2()0
i
f
I �
A. I:
f r
5/LFl) lac A
STEM TO ALLOW 2 9
T/ONAL USEA6E. .3p .
CUK. FROM .TNT '
4
i
RE CRITICAL.
-E FROM DESIGN.
CARE IN SITE PREP.
80NSTRUCTIONNOTES. `_� —�
.y
1
�Unn OF 36 8
FION DISTANCE. --
IELLS&SURFACE WATER. T �
i
,tdUM 5 MINAN RATING.
4C ON SEPTIC SYSTEM. •�y: / / • ;on C, ' ,.I, H,.tlln Cc
'.REQUIRED AT THIS TIME. -. �,
I CONTOUR OF SLOPE. '� X I rir. t� -�•
)DEEPER THAN Ll
'_Y WHEN SOILS
\ m
/stem is
a peak
per day. 1
3
SIGN ONLYI
rYTO OTHER
/EI
RING SITE PREP.
S OVER SYSTEM ryy. s.✓t.P ' h
IROWTH. 7
_ 3 ',
Mt4r e C i AL
�1
51LED FaC A
STEM TO ALLOW
riaNAL USEAGE
c U.0 AeoH THE
W
N U
RE CRITICAL. W
'E FROM DESIGN.
CARE-. IN SITE PREP.
k �
�i
.3
� I C3ED2oonn Y
W HOML
'ONSTRUCTION NOTES.
•v
UM OF 36
%TION DISTANCE. v a•
'ELLS&SURFACE WATER. ?
MUM 5 AIINAN RATING.
IC ON SEPTIC SYSTEM. ��;. SCs13' � / ."� n. '!th tc• r-
RSOUIRED AT THIS TIME.
f CONTOUR OF SLOPE. e ,� /y_;
?DEEPER THAN 2s1 , V 'I� i ❑ ,,:. l�tfrl.Yl
_Y WHEN SOILS
m
h WI J
0 o vi \ S ro
stem is i' 3.
a peak
per day. M�
SIGN ONLYI m
�'TTO OTHER
/EYI
RING SITE PREP.
S OVER SYSTEM b�'' s.Nt is icw.�cN
I°O'ATH. �. 1
z
i o
� z
o .