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HomeMy WebLinkAboutSWG97-00852 - SWG Application / Design / As-Built - 12/30/1997 PEIII MASON COUNTY DEPARTMENT OF HEALTH SERW MIT NO. SWG CES 426 W. CEDAR/P.O. BOX 1666/SHELTON,WA 98584 Date Iz'30-47 < S PHONE (360)427-9670 Receipt No. een71p Amount$ 4A 500. aO Z yd77f PRO n ry r^ CHECK APPLICABLE ITEMS m MAILIN ADDRE$$: DAYTIME PHON NEW SYSTEM a ,d3 O T 3 6 - Z'i 5— 3tF�S REPAIR SYSTEM CITY: / a-w- STATE' ZIP: R -/�9S cZ uy MAINTENANCE REVIEW y� PROPERTY AD PRESS: nn OTHER // c Z J LD 2 Q 'L/9//�� . SPECIFY: B SPECIFIC DIRECTIONS FOR LOCATING SITE: PRIVATE WELL $ 3 Lo 4 COMMUNITY WEWPUBUC SYSTEM SYSTEM WFI M S� •� SYSTEM NAME PPLIC NT '/-'` NAME Name of �+Lot 1`-I/ V ft.x ft. MAILING DRESS . 0• Iw Installer Size: acres TELEPHONE -t N Name of v Designer yL,d-'yd / Bedrooms S IGNATU �I PLOT PLAN \\ � Draw a dimensot plan, including: p ❑Precise Ioceq! of test z �r —' _.------- 5(n 1 G holes,show,,,n�gg measured r)3tAA4 property b[[ §atl ries. c j a,t.0 K , r- ❑Entry ays.(> roads, / N gK S I� tlriveways.� Q7 � I� W p ¢ I " NOTE: DOIyC�j DRAW IN ✓ F I Ci SYSfiEN1 DESIGN a OFFICIAL USE ONLY. DO NOT WRITE BELOW DOUBLE LINE. ©TIST tOLCS1 SOIL LOGS -r�3T�z y Tits G—3` YMDIUA•K S AIV fl O• !_Jf r �IA)£(SleoluNl sxwD a — 5 yJ M-43 g0tirs" gam, Y QKIDIN6To meblkw— Fif U E hOCOWOK 43-Ort 54VOIMM SAW wImii, FPW 0 4311 Wad✓' rlive9tigiAs0PgwjK Ili 1 l�5✓BANG 6W..D rr es eg ✓ IWL� +- 51cwt baY>� okrNe hales - so sw IS were x¢wwJed -^ ab'INIOC Crn c -fto5 + PeJ641 ig w1:1N DESIGNER DESIGNATION SCORES MINIMUM SYSTEM REQUIREMENTS trCGc1c-a7PoL Finding Score I Designer Level: a§One ❑Two �r/pc`��p✓�SgsV,q Soil Type IL 0 Soil Depth 5 In. a Septic Tank Daily P Capacity: Gal. Flow: GPD Slope JI (� x APIA Infik. Parcel Size a'f�? A'c. Role GPD/FT° Area FT- Distance to Shoreline.7�y[� Total In / or D t /2 ��. a� 46 �te COMMENTSJCONDI IONS FOR APPROVAL •All on-afte sewage systems must be designed by a Mason County Certified Designer or a Professional Engineer,unless prior approval Is granted otherwise •All on-sae sewage systems must be installed by a Mason Ccunly Certified Installer,unless prior approval is granted otherwise.In such cases a preliminary on-site mashing between health department staff and the homeowner is required. •On-sRe sewage system design approval does not imply other building site requlremerh;(i.e.RLC,Water Adequacy)have been mat. •Any charge from the specified use of the property or any site akeration art Wing the system design may invalidate this permit. •This psrmti expires 2 years from the date of she review.Denial of this mh my lie apiPealed to the Health Officer within 10 days of denial date. SRE ��InEnW: I�l� �,�� DESI REVIEW: p ad 0Not Appr a INSTTALLAnON.IAppro�,v,,e,,d�gly�.❑Not Ap7prp�v„acid BY: LLLAn�'1 Y W(LWY�ATE: I �GII� BY: 1)•- BVI .INEIACI.�i �IIM'N t4C>DATE:¢vlYr TOP: Health Dept.Copy MIDDLE: Designer's Copy B017OM:Applicant's Copy MASON COUNTY PERMIT ASSISTANCE CENTER Mason County Bldg.III 426 W.Ceder P.O.Box 186 Shelton,WA SEEM (360)427-9670 Beltair(360) 275-4467 Elma (360)482-5269 Seattle (206) 464-6968 DATE: ka TO: n, /A,'}c 'a, Bal.Ldf�-)aw3 1ttoo shearer FROM: LateeAAca&Outo; SU13JECT: EM M, ZA)S 9&-a b0 L PARCEL# d�Y Q SWG# The installation of the on-site sewage system can not be approved until the following items have been addressed: OF &PP—RWO L OF F/N 41- l AJ�;-WLAM (am WeeyClot On-GIle7 gtuv d tsno is ui I LQ r A to - DESIGN FORM - PAGE ONE •• (••a 06.14(94 A design will be reviewed when 3 copies of each of the following items are submitted: }`�} ted design form that has been signed and dated SA ed Resource Lands and Critical Areas Checklist attached ,fV1U(I USA plot plan, including all applicable items on checklist Sca ed layout sketch, including all applicable items on checklist J4N 9 iftross-section sketch, including all applicable items on checklist --------------- !!PERMIT ASSISTANCE CENIER PARCEL IDENTIFICATION Permit Number -2jj4 97 �cg.J z Designer's Name �A✓N/O l /I`1 /� l_C+ II Applicant's Name _TOTC17 b AAA_PM Prop. Owner's Name �A��-P of �lh P4 r," ! u Mailing Address P•U BmY 733 Mailing Address A(iC KlW I /va C. II rC��EArc �p Assessor's Parcel No. /Z 3 Z1 '{Z 01-*060 Subdivision f� �Ijiweive-Digit VumcerTvi c II DESIGN PARAMETERS I I ✓ ✓ �/e 7'unrs - �. fe.irrrmays u?- '00..> II I � Dluen - 2c.rf2 fu,r1 II Designed Vertical I! Separation 4 II !I Mound Subsurface Pressure Gravity Bed Trench / in I! w t c LJ OD Septic Tank/Drainfield Specifications IT-Z5 F .o O.pS.69. .v fn..cl U No. Bedrooms 2 l��'' I ? Yes .�. No Daily Plow Z�/O cud Iis i.......::::: .... LTS _� eW«d. . J e:•••:::...;......•:irl! I Septic Tadk Capacity /� 000 gal I /�rw.t t✓.r ai B)d6- T2.84 �/-6 - I! Receiving Soil Type (1-6) 2B Isq-liS�-I -yQf�'^ Co. .,(r 140 6P0 II I! Receiving Soil Appl. Rate /.0 apd/ft• I m.FXaedeaoa.'3- Laterals 41S/0 - II II Trench/Bed Bottom Area 2 S(O ft' I Schedule/Class Z 72 9 II II Trench/Bed Width ft I Length PC ft II Trench/Bed Length Diameter in I! I! Elevation Measurements I Number !! Orig. Drainfield Area Slope 0 & I Separation ! Final Drainfield Area Slope 0 I Orifices � Depth of Bottom of Trench/Bed I Total Number Of Orifices II ' I! from Original Grade z in I Diameter ! II UPS OF Spacing 1` in I Maei£cld ! opt I Schedule/Class �Bd x II rtr�rr I Length eft Infiltrator Used? U Yea u No I Diameter in rjFr Transport Pipe Pump Required? IJ Yes `V No I Schedule/Class j�sTM z02 £t ....................... (If yes, proceed. . .) Ecii...................iiil Length in II ............ II Diameter Pump/Siphon Specifications I Dozing and Pump Chamhor ! Difference in Elevation Betweenj\Pump Shu f I # Doses/Day al and Uppermost orifice ft I Dose Quantity Rp, n r'I I Chamber Capacity al uppermost Orifice is u higher, u wer 1 !! than Pump Shutoff I Check the �]. wing components if they drain I Capacity ® Tot. Pres. Head m betwe done§"�SPnlyDef�lea)IhServ' s !! I Calculated Tot. Pres. Head ft I Q �/-�[) !! (Attach Pump Curve) I U Lateral W1�DRp Trans port s Date dZ8 DESIGN FORM - PAGE TWO _"- •"a o, =v++ II DESIGN CHECKLISTS I Sealed Plot Plan I Scaled Layout Sketch I Cross-Section Sketch !�/ I Reference depth from orig- r t hole locations I ��Drainffield orientation indl gr de: �f�jj I and layout I I Property lines I [a-, I Septic tank lid and !y/ I Trench/bed dimensions and I drainfield cover depth I r Existing and proposed I critical distances within II wells within 100 ft I layout I Reference depth from orig- II o roperty lines I I inal grade and restrictive �fox/^T"/'•L" locations I strata: - II II Critical distance I I rp� II measurements to cuts, I Lim Septic tank/pump chamber Laterals, trench/bed I b ks, surface water I 1 ation top and bottom II I � Ir II II Location and orientation I Observation port location Cur 'drain collector II of c rain and all I r, II absorption area Cleanout location Sand augmentation I II c mponents I r�� it I'D Manifold placement I No external reference needed: ll [8 cation and dimension I n - ram II of primary system and Orifice placement I u Observation ports and I reserve area r Lateral placement, with u Bu' dings I distances to edge of bed Additional mound information: ll I I Direction of slope Audible/visual alarm I slope and downslope 11 indicator referenced 1 width r� r�9// I Haterlines I '-'�' scale of drawing shown I � Sett d cap depth at I on scale bar I center nd edge of bed II u Roads/easements/ I i r—i II dr eways/parking I Additional Mound Information: LJ Sidewall ope II j Critical resource lands I U Endslo width I U Vp/downslope d elevat. I (if applicable) I r, U Overall fill di 'ons I Comm t d Resource Lands d II North arrow and scale of I i Critical Area. Checklist II drawing shown on bar I II DESIGN APPROVAL III r � II I The undersigned designer does, does not, waive the regirement to be notified by the II installer of the installation and given 48 hours to perform a final inspection prior to cover. S uze dQ. III The undersigned has reviewed and approved this design on behalf of Mason County of Health II Services. / l� Uq Ile aver �nspec yY I II Meson Oounly Dept. Health Services II CAUTION: THIS DESIGN IS ONLY VALID IF STAMPED "APPROVED" BY('br ��,J L`LL)�}f� HEALTH a reja Date Vr- ci 1 r ' Cnedred�—_� Ors_.ems Plat voL�+G•---�-Ordry Nn - l I ! SKETCH OF PROPERTY 5E1 UT IN ATTACHED ORDERI I To assist in locating the promisee It is of hued oe a snrveT, and the compac7 uaamd oo liability far variations, say, is disserMotts sad loadoa 490050 2490060 $p 625 S 8/59 1300000 !490070 2490060 Z400010 2400000 1300050 , O - O s 10/ w° e 98 O SU8IECT ti PROPEIM p rl 0 Ova 4200070 4200060 r 0 E/122 000 3190 - 4200060 070 1020 3190 q 040 $p 631 a y • � sr 14 31 009 purport to 'bow All bighways, roads or easements a$aC.iug the proposr7 r C-a-Tgp�r -- 4µo5-1b p� 211 $Ir'i FA 164 jmRPJ._ , PI'pL✓ —.—• gTi 30 .i Qu<°o \ Ex�r 31d G 9r 5 I40,a1B 7f5layCe /o0 � eveL W I i l�4je J1 r I � a I� s . °V 0 0 sa,6- 97- r7B5.� r 23 7/ yZ o00 60 i I f I Mason County Dept, Health Services APPROVED InItIals aalj D Date A' }laD c 11 - c �O q � M 4 e $ c M c w 1 A ' e W � VVV Ij V o w t, 1 � A ti tv o a E � 80 i e ' IY I Mason County Dept. Health Services GN� APPROVED Dinitialsra E w Date b 1 T �. o L /L3 21 </2 ©Om 60 Mason County Dept. Hearth Servloes APPROVgD D tlele secuam u!wmllu naxTae.� Date MAO KCGAT NIGl11 1 /IMIGM aMaa "IIICCIt" bxst0� IC�I 0 607'. wa / .I"A" meta � namxa•.r I � __ L I� .11aavaG /G/U.17 8Y - - � ORVGT - nuaG a.vl.wTa GIATGR- ,�Pve/?l EXHIBIT `A' A quarter interest in a tract of land partly in the North one-half of the Southeast quarter and partly in the Southwest quarter of the Northeast quarter of Section 21, Township 23 North, Range 1 Went, X.M. , in Mason County, Washington, particularly described as follows: BEGINNING at a point on the East line of the Northwest quarter of the Southeast quarter, said Section, Township and Range where the some intersects the Northwesterly right of way line of Primary State Highway No. 21 (Navy Yard Highway); thence Northeasterly, along the Northwesterly right of way line of said Primary State Highway No. 21, 325 feet; thence Northwesterly at right angles to the Northwesterly right of way line of said Primary State Highway No. 21, 960 feet; thence Southwesterly, parallel to the said Northwesterly right of way line of said Primary State 21, 400 feet; thence Southeasterly at right angles to the said Northwesterly right of way line of said State Highway No. 21, 960 feet, more or legs, to the said Northwesterly right of way line of said State Highway; thence Northeasterly along said Northwesterly right of way line, 75 feet, more or less, to the POINT OF BEGINNING. EXCEPTING THEREFROM right of way for Primary State Highway No. 21 (Navy Yard Highway). ON-SITE SEWAGE INSTALLATION FINAL INSPECTION CLP�tIDAI Use DATE CALLED IN: 1YhiE: � 3 INSTALLER: D�q8 APPLICANT/OWNER: 1 .(F A I CALLER:PHONE N OP CALLER: /� 55/T� ISWG#: / 7 ` 6 B�s� PARCEL NUMBER: ► O- C7� �I c.� - o y o(c 0 SUBDIVISION: �jY A,�I,�i1� Div: Lot. ���'�"v��'�I C mv of SYSTEM TYPE(CHECK ONE): Mao PRESSURE c OF INSPECTION SCHEDULE(CHECK ONE): ❑ ❑ APPOINTMENT PLUG IN AS-BUILT ON-sr E(Ci=ONE): ❑ ❑ YES n No STAFF INITIALS: 77 APPORPITTLNTDATE: TIME: COMMENTS: I I I I ON-SITE SEWAGE INSTALLATION STAFF INSPECTION REPORT STAFF CUR TST Ycs No Comments I. SRPfIC Tau¢ A) >5 ft.Ram foundation? H) >50 R from wells and surface water? C) Bldg stub-out to septic tank:clean-out if not 1-2%? D) Baines intact and clean? E) Dividing wall intact? — F) Risers installed for access? B. D) Leveled with water and/or speed leveler(circle)? N I¢ 1)RAwFmcp A) >10 ftfiomfoundationand>5 ft from perceived propertylines? B) >100 ft Rom wefts and soda,,water? C) >10 It from potable water lines? D) Laterals level to±1 inch R end caps present if not looped? E) Gmvellm chambers utilized? F) Systern dimensions the sere,as shown on the design? G) Gravel clean,property sized,and proper depth? H) pRFBaORg SraxRass 1) Sand quality ASTM C-33? 2) Heed heightuniform and z24 inches? _ 3) Clesrr-outs and observation ports present? 4) Mound: Side Slope 3:17 5) Owner informed electrical connections must be made by owner or licensed electrician and inspected by L&M IV. Prmre/Puw CerA&cam A) Screen basket or effluent filter(circle one)installed? _ { .�)L') IW'V�1 B) Riser installed for access? C) Alarm installed? D) Pump oa timer or demand(circle)? V. As-B=RF.Qrmteu? — V1. GTrum COMA4'Ms/GasMvknONs The undersigned has reviewed this installation and verifies these findings on behalf of Mason County Departramt of Health Services, uALQ � �OCJAVSd 4� Samtanan Date C:VA,TilaaVi uchedcapd Rcayscd M6N7 AS-BUILT FORM Revised Febmary 18, 1998 ?r r_ � PARGELiGENTIOICATION Applicant UX� e, _5 11-a- IL.- Assessor's e � parcel# L z 3 Z/l�zOOG(o0 _ Permit Number SWG LNL- 78 z- S(Twelve-Digit Number) Installer P) tlj'-`5 Q YtY&-b,4abdivision " 7 (NamelDivislontalocWLon Designer a't. 'u I�--rM� INSTALLER CHECKLIST NIA Yes Prior to Completion I. SEPTICTANK 1 A) >5 ft.From foendationl . . . . . . . . . . . . . . ......... ........ ... .. .. . B) >50 ft from wells and surface water? . ... ..... ........... ..... _.. Q Bldg stub-out to septic tank:cle snout if not 1-2%7 ......... ... ..... D) Baffles intact and clean? .. . . . .. ...... .... ........... ... .. ..... � _ E) Dividing wall intact?. . . . .. . . . .. .. .. .. .. ......^..... ... .. ..... F) Risers installed for access? .. .. .. .... .. .. ............. . . . .. — G) Tank Size:_/Z" gal.;Manufacture �' 1,(_cRY II. D-Box A) Leveled with water? . . .. ....... .. .. .. .. .. ... ........ . ......... ✓ B) Speed leveler used? . . . . ......... ...... .. ..................... III. DRAINFIELD v 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 not looped? .. ......... E) Gmvelless chambers utilized? . . .. .. .. .. .. .. .................... JV — F) System dimensions the same as shown on the design?................ G) Gravel clean,properly sized,and proper depth? ... ... . .. .......... . �L H) PRESSURE SYSTEMS 1) Send quality ASTM C-337 2) Head height uniform and z24 inches? Actual head height 3) Clean-outs and observation ports present? 4) Mound: Side Slope 3:11 . .. . . .ions connections - 5) Owner informed electrical ectlons most be made by owner or licensed electrician and inspected by L&I? .. . .. ........ - IV. PUMPIPUMP CHAMBER A) Pump make ; Pump model V — B) Chamber size gal; Mawfacdue —1, - C) Height of pump off bottom of pump chamber inches —L, D) Pump chamber draw-down gallons per inch E) Pump capacity gallons per minute F) Pomp controls:Timer(or)Elapsed Time Meter (circle if installed) If timer is used:Pump On Pump Off ✓ - - - G) Screen basket o ffitumt le one)installed? .. ... .. . . . .. .... —� — H) Riser installed for access? . . . .. . .. .. .. .. .. . . . . . . . _ . . .. . . . .. .. ... . I) Alarm installed? . . .. .. .. .. . .. .. ....... . . . . . . . . . . .. . .. . . .. . .. . AS-BUILT.DRAWING CHECKLIST ❑ Drainfield&manifold orientation & layout loegaeEs / �' � fI ❑ Trench/bed dimensions ---� and critical distances_, i1 within layout O.P ❑ Septic/pump tank r_ _ _ �'(S It placement. ❑ Location of buildings. ❑ Observation port&dean_- — 5 out location. ❑ Location of wells& roads. ❑ Undisturbed native soil between trenches. ❑ North arrow l s'da�� 13z- C.AI1TiON:Minor adjustments la septic fork,locadon and dramfield orientation made in the field by on installer are generally acceptable to born the department and me designer,but could in certain cases compromise me viability of me system. It is the installer's tespomibility w obtain pnor written approval ham ermer me health department or me designer before making any deviations from me design that affect me system viability. Any deviations from theappmval fdesign romsmustbe shown above. CERTIFICATION OF INSTALLATION Installer Check a box from Row "A"and'B", sign and date the certification A. [ I certify that I installed the system without any ❑ I certify that all deviations from the design stamped deviation from the design stamped"APPROVED"by "APPROVED"by MCDHS are shown above. MCDHS B. ❑ I certify that I contacted the designer and left the q(1 I did not contact the designer prior to final cover because the system open for inspection up to 48 him prior to / ` designer waived the notification requirement. cover. I further certify that all information contained on this form is accurate. I understand that if the information contained herein is not accurate,there will be just cause for immediate suspension of my installer certiii 'an, � Signature re of rInInstaller ate The undersigned approves this installation on behalf of Mason County Dep eat of Health Services. 7�� Eime �ina AC82aoN 4 lqe