HomeMy WebLinkAboutSWG2025-00106 - SWG Application / Design - 4/7/2026 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON:360-427-9670,EXT 400
I. BELFAIR:360-275-4467,EXT 400
Public Health & Human Services ELMA:360-482-5269,EXT 400
FAX:360-427-7787
On-Site Sewage System Permit: SWG2025-00106 CbU
APPLICANT SIEBENHOR AURA Phone:
Address: 11 NE SAIL LOFT CT BELFAIR, WA 98528
OWNER SIEBENHOR AURA Phone:
Address: 11 NE SAIL LOFT CT BELFAIR, WA 98528
SEPTIC DESIGNER Jim Zimny Phone: 360-516-7287
Address: 7178 WINDFLOWER PL NW SEABECK, WA 98380
SEPTIC INSTALLER RICHARD MOORE* Phone: 360-509-1342- Rich
Address: PO BOX 963 BELFAIR, WA 98528
Site Address: 11 NE SAIL LOFT CT
Primary Parcel Number: 123315100003
Permit Description: Repair 3bd gravity trench
Permit Submitted Date: 03/31/2025
Permit Issued Date: 05/08/2025
Issued By: Rhonda Thompson
Current Permit Fees Paid: $825.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 04/07/2026 (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 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 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.
DATL rscElveD: OFFICIAL USE ONLY
MASON COUNTY 13 o'.c S O N
I COMMUNITY SERVICES AMOUNT RECEIVE
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Pu6Lk Health(Community Hea@h/Environmental Health)U • rij
0-627-9670,ext 400 or 3 0-275-4 67,ext 400
415 r.6th Sheet-Shelton,WA 98584 S �WG , -co I o Pa
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CLEAR FORM ON-SITE SEWAGE SYSTEM APPLICATION v
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APPLICANT PHONE m m
AURA SIEBENHOR }63 Z
MAILING ADDRESS-STREET.CITY,STATE,ZIP CODE ] W
11 NE SAIL LOFT CT BELFAIR WA 98528 fr
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SITE ADDRESS-STREET,CITY,ZIP CODE `
11 NE SAIL LOFT CT BELFAIR WA 98528 c (,--
NAME OF DESIGNER PHONE
360-516-7287 P I f V
Jim Zimny
NAME OF INSTALLER PHONE v I I ^'�
SOUTH SHORE CONSTUCTION 360-509-1342 ( �V
DRINKING WATER SOURCE 5 (V
PERMIT TYPE(select one) O
Pt-RESIDENTIAL OSS h COMMUNITY OSS Ih COMMERCIAL OSS 5 PRIVATE INDIVIDUAL WELL h PRIVATE TWO-PARTY WELL Z I
la PUBLIC WATER SYSTEM LYNCH COVE WATER
TYPE OF WORK(select one) 1
6 NEW CONSTRUCTION/UPGRADES IR REPAIR/REPLACEMENT OTHER DETAILS(select all that apply) ❑ TABLE IX REPAIR oa I
SUBMITTALS 0 SURFACING SEWAGE 0 EXISTING FAILURE 0 SHORELINE
CO DESIGN FORM(REQUIRED) iPi SEPTIC DESIGN(REQUIRED) BEDROOMS 3 LOT SIZE 0.27 r I
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h-WAIVER(S)(IF APPLICABLE) n
DIRECTIONS TO SITE AND SITE CONDITIONS(ex ticked gate) 0
FROM BELFAIR TAKE NORTHSHORE RD .9 MILES AND TAKE RT ONTO SAND HILL I Q
RDGO UP SANDHILL RD .4 MILES AND TAKE LEFT ON LARSON BLVD. FOLLOW
FOR .9 MILES TO SAIL LOFT CT AND TURN INTO CULVSAC. HOUSE IN ON THE LEFT. r I C
TEST HOLES ARE IN THE BACK YARD ltiI O
SITE MUST BE FLAGGED FROM MAIN ROAD AND TEST HOLES MUST BE FLAGGED WITH TEST HOLE NUMBERS. I
OFFICIAL USE ONLY BELOW THIS LINE
UPGRADE/FAILURE SOURCE(for reporting purposes)
❑VOLUNTARY ❑MAINTENANCE/PUMPING 0 BUILDING PERMIT OHOME SALE ❑COMPLAINT ❑OTHER:
INSPECTOR SOIL LOGS COMMENTSI CONDITIONS
1;.\1* (0 6-7.. i 9,070"141A/V1 al 1-1 6:=17_01
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r\-\,\-/,-, 6-5-- (15 L, r5144-1,(5i40,471 ,
IN) q(DY) 04— (15)1-11-6.111'L — 4,:tZt 4
L7 N 161
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RECORD DRAWING AND INSTALLATION REPORT
SOIL CODES:
V=VERY G=GRAVELLY S=SAND L=LOAM Si=SILT C=CLAY E=EXTREMELY R=ROOTS REQUIRED FOR FINAL APPROVAL.
INSPECTOR SIGNATURE DATE APPLICATION EXPIRATION DATE APPLICATION APPROVED/ISSUED BY DATE
�Vi \-k< \IVY° QINLIA11 .5 1 c (?)/
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE REVISED 12/7/2015
DESIGN FORM—PAGE ONE Assessor's Parcel Number: 123315100003- --
A design will be reviewed when 3 copies of each of the following are submitted:
'1 Completed design form that has been signed and dated. '1 Scaled layout sketch,including all applicable items on checklist
'1 Scaled plot plan,including all applicable items on checklist. '1 Cross-section sketch.including all applicable items on checklist.
This form may be scanned and available for public view on the Mason County Web site.Maximum paper size: I I' X 17'.
PARCEL IDENTIFICATION
Permit Number: SWG TO'2 'wl 0 6 Designer's Name: Jim Zimny
Applicant's Name: AURA BIEBENHOR 360 516 7287
Designer's Phone Number:
11 NE SAIL LOFT CT Designer's Address: 7178 WINDFLOWER PL NW
Mailing Address: g
BELFAIR WA 98528 SEABECK WA 98380
CLEAR FORM
City State Zip City State Zip
DESIGN PARAMETERS
Treatment Device
❑ Glendon Biofilter 0 Sand Filter 0 Mound 0 Sand Lined Drainfield 0 Recirculating Filter,Type:
❑Aerobic Unit Make/Model 0 Disinfection Unit Make/Model Other:
Drainfield Type
Nf Gravity 0 Pressure lErTrench 0 Bed 0 Sub Surface Drip
Septic Tank./Drainfield Specifications Laterals
Number of Bedrooms 3 Schedule/Class 3034
Daily Flow: Operating Capacity 270 gpd Length 50 ft
Daily Flow: Design Flow 360 gpd Diameter 4" in
Septic Tank Capacity(working) 1125 gal Number 4
Receiving Soil Type(1-6) 4 Separation 5 CTC ft
Receiving Soil Appl. Rate U.6 gpd/ft` Orifices
Required Primary Area 600 ft2 Total Number of Orif ►s NA
1
Designed Primary Area 600 ft2
Diameter �P�. ttt in
Designed Reserve Area NA ft2 Spacing „1 'it in
Trench/Bed Width 3 ft ' anifold
TrenclvBed Length 200 ft Schedule/ "�r ".*�t►t NA
Elevation MeasurementsLength "`t *'a_ „ +c
ft
Original Drainfield Area Slope 5 % Diameter in
New Slope.If Altered 5 % Preferred manifold configuration used? 0 Yes 0 No
Depth of Excavation Up-slope l 2. in Transport Pipe
from Original Grade Down-slope .q in Schedule/Class 3034
Designed Vertical Separation L(0 in Length 30 ft
Gravcllcss Chambers Required? 0 Yes 0 No ErOptional Diameter 4 in
Pump Required? 0 Yes 0 No Dosing and Pump Chamber
Pump/Siphon Specifications Number of doses/day NA
Diff. in Elevation Between Pump&Uppermost Orifice ft Dose quantity gal
Drainfield Squirt Height/Selected Residual(head) ft Chamber Capacity(flood) gal
Uppermost Orifice ❑Higher 0 Lower than Pump Shutoff Pump controls:Please check those required.
Capacity @ Total Pressure Head gpm ❑Time p Meter 0 Event Counter
Calculated Total Pressure Head ft If Timer Pui J O ;Pump off
Comments MAY 0 8 2025
MASON COUNTY ENVIRONMENTAL HEALTH
RET
DESIGN FORM-PAGE TWO Assessor's Parcel Number. 123315100003- --
Permit Number. SWG
DESIGN CHECKLISTS
Scaled Plot Plan Scaled Layout Sketch Cross-Section Sketch
El Test hole locations fa Drainfield orientation and layout Reference depth from original grade:
V Soil logs I V Trench/bed dimensions and i Septic tank
El Property lines I critical distances within layout I WI Drainfield cover
Existingopeand r�n�cP.l wells V D-Box/Valve box locations
p p-sed we Reference depth flout original glade
within 100 ft of property - V Septic tank/pump chamber and restrictive strata:
✓ Measurements to cuts,banks, and locations 0 Laterals,trench/bed,top and
surface water and critical areas VI Observation port location bottom
0 Location and orientation of is Clean-out1� location 0 Curtain drain collector
curtain drain and all ahsnmtinn I pV manifthi plat iucnt ❑ Sand augmentation
components ❑ Orifice placement Other cross-section detail:
O Location and dimension of 0 Lateral placement with distance 0 Observation ports/clean-outs
primary system and reserve area to edge of bed
0Buildings g Other Information
❑ Audible/visual alarm referenced Yes No
Direction of slope indicator 0 Scale of drawing shown on scale 0 V Design staked out
O Waterlines bar I D 0 Recorded Notices attached
el Roads,easements,dnveways, G k Waiver(s)attached
parking 0 0 Pump curve attached
Ear North arrow and scale drawing ,�',' 0 [�Evaluation of failure
shown on scale bar 4
ry �� Non-residential justification
�r t. �fi 0 Er Waste strength
�, iii ' ` 1 Cl Er Flow
I PC.`--'''. - Vila
The undersigned designer must be notified /y nstaller aft me nstallation li Yes 0 No
Signatu irresigner Date
The undersigned has reviewed this design on behalf of Mason County Public Health and determined it to be in
] ccmpliance ri ibli SWYM lc cal VYY-site]Vfq a]Q4.1V]lb.
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Environmental I-Iealth Specia_ist Date
CAUTION: DESIGN APPROVAL IS VALID ONLY UNDER THE FOLLOWING CONDITION:
✓ The design is stamped "Approved"by Mason County Public Health.✓ The Onsile Sewage Permit has not expired;.jhe Permit F.xpinitinn i:lir. i.- f 1�/2-C
✓ 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.
i
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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Advantage Perc & Design
Ilmely•Reasonable•30 Years of Local Lxperience
Construction Notes for 3 Bedroom Gravity System
Gravity w/graveless chambers (Rock and pipe may be substituted)
Install 4-50' Laterals .
use a b hole d-box and speed levelers
Install on 5'foot centers.
Install¶ trench depth on low side of trench and maintain 36" of vertical separation
Install level and along contours.
Install in dry weather only. ROVED
Use 1125-Gallon septic and add risers for pumping and maintenance A P P
MAY 0 8 2025
System designed for typical residential waste strength sewage only. MASON COUNTY ENVIRONMENTAL HEALTH
System designed for 360 Gallons Per Day RET
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