HomeMy WebLinkAboutBLD2015-00810 - BLD CD Environmental Health Review - 9/18/2015 MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
October 13, 2015 PO BOX 1666 Shelton WA 98584
Shelton (360)427-9670
Fax (360)427-8442
ULVERT YOUNG Elma (360)482-5269
550 NE HAVEN LAKE DR
TAHUYA WA 98588 Belfair (360) 275-4467
Case No.: BLD2015-00810 Parcel No.:223305000325
Dear Applicant:
Your building permit will not be approved by Mason County Public Health until the following
items are completed and received in our office.
Satisfactory Operation and Maintenance report from a licensed Operation and
Maintenance Specialist with in the last year.
Please call me at (360)427-9670, ext. 353 if you have any questions.
Sincerely,
Cindy Waite
Environmental Health
Mason County Health Services
Comments:
10/13/2015 Page 1 of 1 BLD2015-00810
COMMUNITY DEVELOPMENT ENVIRONMENTAL HEALTH REVIEW
Mason County Public Health Official use only
415 N. 6th Street Permit Number: 2 \5-0: VI 0
PO Box 1666
Shelton, WA 98584 Date Received:
Shelton: (360)427-9670, Ext.400
Belfair: (360)275-4467 Ext.400 Amount Received
Elma: (360)482-5269 Ext. 400 Receipt Number
Fax (360)427-7787
Applicant Inform tion Type Review
Applicant Ui yi— DateOrf 1g115 Buildi ermit
Marlin. Address 1 44 New 0 Replacement
9 • l ,i WA Z 0 Commercial Building Permit
City GGll State Zip
0 New CI Replacement
Daytime Phone U'2 O& her Phone 0 Building/Commercial Permit Revision
❑ Tenant Review
E-Mail Address $huirsilcveOc1 C(/{1/1 0 Pre-Application
Parcel Information
12-Digit Parcel Number 22 G — S0"003 Z
Site Address J C, 0 �V 14 GvsUI ( Gt rp dr. 1 G 1 t,vo
Street Number Street Name City
Type of Job Please submit a scaled plot plan
Describe work I VS-1-Lk 2 FA- ti6,1/1 . Itt rvq showing all existing and proposed
Number of Bedrooms 2 building, on-site sewage system,
and well.
On-S" ewage Information — Water System Information
D O /e Septic System 0 New [r Existing Plumbing in structure? II‘ 0 No
❑ Sewer Name of Sewer System If yes:
Using an existing on-site septic system will require a current Please submit a completed Water
maintenance report and a Record Drawing (Asbuilt). Documents
for both of these requirements may be on file with Mason Adequacy Form.
County Public Health. Other requirements may apply.
A lic i tur
Date
Official use only
Departmental Review Approved Denied Notes
Water Adequacy
On-site Sewage System
Tenant Review
Revision
Revised 12/17/09
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r:I s Silo Flan doe, not constitute a 029"LF$ 10-29" a� North Scale
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iess:onal land ,urvcy I
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s ; -• > v l', rt2OERTY OWNEt2:PavldMcConnell THE WETLANt2 CORPS
' m m k O FAI2CEL : 2230 -50 -00325 �nvironmentalPerm ittinq
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and Septic Design 1
L , o 7 N 1:n5 GNt2: Joe Gilbert pOaok 2854
12f2AWN f3Y: Joe Gilbert/ Megan 0oad Delfair. WA 95528
RECORD DRAWING
CHECKLIST G
E Drainfield& ,,,,,•�
manifold orientation ' i`
& layout
Dr-Trench/bed (2 ."45.
dimensions and `
critical distances W4,1j
within layout 1: .... •�j
'Septic/pump tank r' /
placement ',IAt
ite'�
Dr-Location of h t, 5
buildings 40, A -4
fsh
lekjoat
IN- Observation port& HeX 11
clean-out location ` . 0 ~ ,
E Location of wells&
roads
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( Undisturbed native
soil between (-16Gir
trenches
Efr1 orth arrow f ._ *el'``p i
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CAUTION:Minor adjustments to septic tank location and drainfield orientation made in the field by the installer are generally acceptable
to both the department and the designer,but could in certain cases compromise the viability ofthe system. It is the installer's responsibility
to obtain prior written approval from either the health de_partment or the designer before making any deviations from the design that affect
the system viability. Any deviations from the approved design must be shown above.
CERTIFICATION OF INSTALLATION
Installer: Check a box from Row"A"and"B",sign and date the certification
A. girl certify that I installed the system without any 0 I certify that all deviations from the design stamped
deviation from the design stamped"APPROVED"by "APPROVED"by MCPH are shown above.
MCPHMC
B. C�1 certify that I contacted the designer and left the 0 1 did not contact the designer prior to final cover because the
system open for inspection up to 48 his prior to cover. designer waived the notification requirement.
1 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 certification. SG�,�C4a4,44,__6,/ ,.(,„„__
Signature of installer D
The undersigned approves this installation on behalf of Mason County Public Health.
. gfrisit_ 6.4l/z
Environmental Health Specialist Date
Revised January 2008
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