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HomeMy WebLinkAboutSWG2024-00381 - SWG Application / Design - 9/12/2024 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584 SHELTON:360-427-9670,EXT 400 J BELFAIR:360-275-4467,EXT 400 Public Health & Human Services ELMA:360-482-5269,EXT 400 FAX:360-427-7787 On-Site Sewage System Tank Only Permit: SWG2024-00381 APPLICANT Kelly, Serena Phone: 3603734404 Address: 7124 State Hwy 3 SW Bremerton, WA 98312 OWNER SIMS DAVID L&TERESA D Phone: Address: 25006 MORGAN ST BLACK DIAMOND, WA 98010 SEPTIC INSTALLER JUSTIN WELLS* Phone: 360-536-4431 Address: 7124 STATE HIGHWAY 3 SW BREMERTON, WA 98312 Site Address: 141 NE VIEW CT Primary Parcel Number: 222025900006 Permit Description: Addition of Tank for Proposed 1 bd ADU Permit Submitted Date: 09/12/2024 Permit Issued Date: 09/12/2024 Issued By: Rhonda Thompson Current Permit Fees Paid: $530.00 (additional fees may be required upon installation of system). Permit Expiration Date: 09/12/2027 (based on date of inspection) Type of Work Other Components being Replaced: Septic Tank Only Surfacing Sewage? No Existing Failure? No Shoreline? No Horizontal Setbacks Met? Yes Number of Bedrooms: 5 Drinking Water Source: Private Well/Spring Additional Details: Adding tank for proposed ADU &connecting to existing system Permit Conditions: 3 Mason County Asbuilt Form, Record Drawing, and Installation fee must be submitted for final installation approval. 4 Proposed development subject to zoning requirements and approval by the planning department staff per Mason County Title 17. 1 Horizontal setbacks per WAC246-272A-0210 must be maintained, unless prior approval is obtained 2 Permit must be installed by a Mason County Certified Installer unless prior written authorization from Mason County is obtained. 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/OR 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. 0, OFFICIAL USE ONLY MASON COUNTY DATE RECEIVED, 9/12/2024 COMMUNITY SERVICES AMOUNT RECEIVED: 530 RECEIVED BY: C co cn online o rn Public Health(Community Health/Environmental Health)0 a' 360-427-9670,ear.400 ornWA9-u67,eat 400 sw 2024-00381 0 415 N.Sth Street-Shelton.WA 98S8a Z 6 ON-SITE SEWAGE TANK ONLY APPLICATION m APPLICANT PHONE rn Ja1 O ((onnt i l 3(P - 37 .- (--p-/oy MAILING ADDRESS-STREET,CITY,STATE,ZIP CODE g �I 1)tj & `/ 5 m SITE ADDRESS-STREET.CITY,ZIP CODE • /ti / it) vi-e,u.J c e'?1 f r lid A- NAME OF DESIGNER PHONE N `� NAME OF INSTALLER PHONE v I{ V JaAD C- 3(,0 — 3/3 -LP-Ny R I TYPE OF WORK(select one) DRINKING WATER SOURCE O NEW CONSTRUCTION/UPGRADES ❑ REPAIR/REPLACEMENT ..PRIVATE INDIVIDUAL WELL 0 PRIVATE TWO-PARTY WELL Z I COMPONENT(SAriEPT C)TANK TO BER 0 PUMP TA KLE D 0 RV HOLDING TANK BED❑ROOMSLIC WA SYSTEMS LOT SIZE I ICN ❑ OTHER 0.59 I-I— I OTHER DETAILS(select all that apply) TANK(S)SETBACK CHECKLIST 0 I ❑ SURFACING SEWAGE 0 EXISTING FAILURE 0 SHORELINE Er 100FT+PUBLIC/COMMUNITY WELLS SUBMITTALS la50FT+PRIVATE WELLS,SURFACE WATERS,STREAMS,RIVERS \v\` ❑ PLOT PLAN(REQUIRED) TANK CROSS SECTION(REQUIRED) J 10FT+DRINKING WATER SUPPLY LINES ❑ PUMP DETAILS(IF APPLICABLE) 0 WAIVER(S)(IF APPLICABLE) T 5FT+PROPERTY!EASEMENT LINES,FOUNDATIONS,FOOTINGS r PLOT PLAN CHECK( L Q ❑ PROPERTY LINES AND EASEMENTS 0 EXISTING/PROPOSED STRUCTURES 0 EXISTING!PROPOSED OSS COMPONENTS AND LINES —1 ❑ WELLS WITHIN 100FT 0 WATER SUPPLY LINES 0 DRIVEWAYS/PARKING 0 SURFACE WATERS,STREAMS,RIVERS.ETC... p ❑ DIRECTION OF SLOPE!CONTOURS 0 PERIMETER/CURTAIN DRAINS ❑NORTH ARROW 0 SCALE BAR DIRECTIONS TO SITE AND SITE CONDITIONS:(ex.locked gate) OFFICIAL USE ONLY BELOW THIS LINE UPGRADE I FAILURE SOURCE(for reporting purposes) ❑VOLUNTARY 0 MAINTENANCE/PUMPING 0 BUILDING PERMIT ['HOME SALE ['COMPLAINT El OTHER: COMMENTS/CONDITIONS Adding a new septic tank for proposed ADU 4 SEWAGE TANKS MUST BE LISTED UNDER DOH"LIST OF REGISTERED SEWAGE TANKS". TANKS MUST MEET CURRENT MINIMUM SIZE REQUIREMENTS,EQUIPPED WITH RISERS AND LIDS TO SURFACE,AND INCLUDE AN EFFLUENT FILTER(IF APPLICABLE). RECORD DRAWING AND INSTALLATION REPORT REQUIRED FOR FINAL APPROVAL. INSPECTOR SIGNATURE DATE APPLICATION EXPIRATION DATE APPLICATION APPROVED/ISSUED BY DATE 9/12/2027 R Thom son 2024.09.12 P 11:33:56-07'00' THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE REVISED 12/7/2015 y II * , 1 l 1 1 1 1 I 1 F 00KV"D1i000zv00mZiz 4 0 P _i r r ii ,Xro amco,; m •1% r 14g im- ° 00 a" 0{ m<- =-0 6 rA ri00Zmi <1p"101 20>m D R w 44,... n OZy) 1iaS1pOc0fmzzI r h, m m 14,, i ujIIflJU!1i: - � pO °a m m o 9 ���� i � ; A m, 3 4 z •0ziozoz o 011 EH APPROVED a pad ;;':f''"f A IE "- vor 1 Rhonda Thompson 09/12/2024 f,i' t•0 iI!!flflil 'Olf0)i1A<)nmA° 1 Dh m €F' c"o33i0A°pmZmomS4i ( ' rZ 0°p0m5 m pmgxi" 1 m l ! o°°q"o2p�j>• )°DpZ)1J r co g $_tai <2 ,Z0D0"1Dz;3oi1" C •(. ,,€ 4 rrp• zoo sg,gr,°Aln " .,r` ito;rDi .1.i_oA�1.p I m pg. 10°{1"A<p<Oncx @ 't,0;m )0pp0 3 cczp1 )1 B Dc)0 {"z {^,� ma3OO Aia< z m-i13�r mzi z prim zN1'4fl U N.`2" o 0 -i 2W91 r y ' o i £0 ; T2 "MI � oA_g a Rib n A D g A x m m 4 AA ?sou' Cpi < :A1Zr „m ill r ?a �00� 0 ZT Ic 0) zZAO 0^� O 0 m< m m�m 1 cm ZO m1 - ) -i > Iii11711! ...s. . as° _L X x n�It� 1 ! `fro `� en m I 1 1 1 1 m •tea e "..:'•'; 3 e o A o o Z m ,n o m _� v1C m £ � oo m � • pew ,. ..._...:: 1 -4 m 2 . D a AZrO Zi Z.•:' ''' 0 Z •,. ti . Cn —I Z p : :1, :.: X i> -D-I > .1?:;:::::::,::.:.,:•:;.:..: 1,) ` 4 N m K N. O W q 1'ri N.) � 77 Q K \. \ S o 1 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG 2024-00381 Parcel # 22202 59 00006 Applicant Name SIMS, DAVID L & TERESA D Subdivision (Name/Div/Block/Lot) Applicant Address ji-lt P V r p c,i c-k- City, State, Zip Zek i t`- w N. , cte.c.) Installer Name j 0'(cn,42 \I Site Address ty I IA,' 1.11t w ( f- Designer Name INSTALLATION CHECKLIST ❑ Full System Installation 'Tank(s)Only ❑ Drainfield Only iN Repair ❑Other System TypeAdd a new septic tank for proposed ADU Pretreatment Type 0 (A- >5 ft.from foundation? - - ❑ N/A fg YES ❑ NO >50 ft.from wells? - - ❑ [A ❑ Z >50 ft.from surface water? - - ❑ IO El H El between building and tank? - - ❑ f U Tank baffles present? - - ❑ ® ❑ a El El access risers over each compartment?- - ❑ W Effluent filter installed?- - ❑ ❑ ❑ N Septic tank capacity(working) f 6te 0 gal Manufacturer NA 9 D-box water level and speed levelers used? - - ® N/A ❑ YES ❑ NO O(7) Ill ❑ ElManifold/D-box accessible from surface?- - mZ Check valves installed? - - ® ❑ ❑ OQ 2 Transport Line Size Schedule/Class Bedrooms installed (check one) ❑ 2 ❑ 3 ❑4 ❑6 ❑Commercial/Other >10 ft. from foundation?- - ❑ N/A ❑ YES ❑ NO O >100 ft. from wells?- - ❑ ❑ ❑ W >100 ft. from surface water? - - ❑ ❑ ❑ LL >10 ft. from potable water lines?- - ❑ ❑ ❑ Z > 5 ft. from property lines and easements?- - ❑ ❑ ❑ • > 30 ft.from downgradient curtain/foundation drains? - - ❑ LI ❑ o Drainfield level and observation ports present - - ❑ LI ❑ ❑ Graveless chambers or ❑ Clean gravel used? (check one) Proper cover installed over drainfield?- - 0 ❑ LI Pump tank setbacks consistent with septic tank? - - ❑ N/A ❑ YES ❑ NO • Pump tank capacity (flood) gal Manufacturer < 24" access riser(s)and accessible from surface?- - ❑ ❑ ❑ 1— IL Alarm or Control Panel Installed? - - ❑ ❑ ❑ 2 Control Panel equipped with Timer/ ETM/Counter- - ❑ ❑ ❑ m a- Pump installed in ❑ Bucket or ❑ On Block or ❑ Other d• Pump Make/Model ❑ Floats or ❑ Transducer a Tank draw down in/min Pump capacity gpm Squirt Height ft Pump on time Pump off time Daily flow set at gpd Updated 8/2 112 0 1 8 RECORD DRAWING (continued) i Mason County OSS Installation Report pg. 2 Parcel# ABANDONMENT RECORD Were existing septic components abandoned as part of this project? - - ❑ YES g NO If yes, please describe: Were all components pumped out and properly abandoned per WAC246-272A-0300? - - ❑ YES ❑ NO RECORD DRAWING This is a permanent record and must be accurate and descriptive enough to re-locate In the need of maintenance activities and future development. Typical Record Draw ngs contain: Drainfield&manifold orientation S layout.Septic/pump tank location,North arrow,reserve drainfeld,existing and proposed buildings,location of wells,waterlines. wells,observation ports,deanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays in final Installation approval and related permits. r �n . i\\N'') 9 ri k.x.&\)° VCR /4 L') ;sE t4j emu/ Diu a5r a folio `t7 thr4'rwff -r G>CISH4 ,�y L. 3eocSti51-en ) , (ztit_ ❑ Record Drawing Attached CERTIFICATION 0 1N TALLATION INSTALLER flE GNER/ ENGINEER 4 I certify that I installed the system in accordance with I c ify that the system has been installed in accor- the septic design stamped 'APPROVED"by Mason dance with the septic design stamped"APPROVED"by County Public Health and that any deviations shown Mason County Public Health and that any deviations here have been cleared/approved by both the designer shown here have been cleared/approved by both and Mason County Public Health and meet all State myself and Mason County Public Health and meet all and Mason County Codes. State and Mason County Codes I further•-rtify t.at all info matio' contained on this I further certify that all information contained on this fo - .• atta. -, Recort Drawi g is accurate. form and attached Record Drawing is accurate. `..A p iZ 2-9 Sig a Lure of I alter Date )cc nc G-, O C.6 .'s rt Ll Printed Name of Signee MASON COUNTY PUBLIC HEALTH The undersigned approves this Installation Report and Record Drawing on behalf of Mason County Public Health: R Thompson 2024.09.12 11:33:13-07'00' Signature of Environmental Health Specialist Date (stamp, signature and date) THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 8/21/2018 7 N r r g V O m-I G) m ' % �D aw li tQu m ci. ,� 4 d5r m is mA1 i „ 'i�/ fl m r• o EH APPROVED �'.,, •'''� Z i. 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