HomeMy WebLinkAboutSWG2024-00367 TANK ONLY - SWG Application / Design - 8/27/2024 OFFICIAL USE ONLY
DATE RECEIVED: 9/17/2024
MASON COUNTY J
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COMMUNITY SERVICES AMOUNT RECEIVED. RECEIVED BY
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Rhonda CO m
—/ Public Health(Community HealthiEnvironmental Health) (i)
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<ISN nt�Street Shelton.WA 9858d
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ON-SITE SEWAGE TANK ONLY APPLICATION
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APPLICANT PHONE
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SAM SKINNER 360 537-7678 z
MAILING ADDRESS•STREET.CITY.STATE,ZIP CODE E
PO BOX 920, EAST OLYMPIA, WA 98540 DJ
73
SITE ADDRESS-STREET,C,TY ZIP CODE
191 E NORTH ISLAND DR, SHELTON, WA 98541 I‘k
NAME OF DESIGNER PHONE 15)
JIM HUNTER 3560 753-1226
NAME OF INSTALLER PHONE 0 IC
SKINNER CONSTRUCTION 360 537-7678 <_ IG
DRINKING WATER SOURCE
TYPE OF WORK(select one) DRINKING
O NEW CONSTRUCTION I UPGRADES 0 REPAIR/REPLACEMENT g PRIVATE INDIVIDUAL WELL ❑ PRIVATE TWO-PARTY WELL Z I
COMPONENT(S)TO BE REPLACED/INSTALLED 0 PUBLIC WATER SYSTEM 1
❑O SEPTIC TANK 0 PUMP TANK 0 RV HOLDING TANK BEDROOMS LOT SIZE 0.84 IG,�
❑ OTHER 3, W
OTHER DETAILS(select all that apply) TANK(S)SETBACK CHECKLIST 0 .
❑ SURFACING SEWAGE 0 EXISTING FAILURE 0 SHORELINE 0 100FT+PUBLIC/COMMUNITY WELLS n 1
SUBMITTALS ElSOFT+PRIVATE WELLS,SURFACE WATERS,STREAMS,RIVERS
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❑ PLOT PLAN(REQUIRED) 0 TANK CROSS SECTION(REQUIRED) 0 10FT+DRINKING WATER SUPPLY LINES ID
❑ PUMP DETAILS(IF APPLICABLE) 0 WAIVER(S)(IF APPLICABLE) 0 5FT+PROPERTY/EASEMENT LINES.FOUNDATIONS.FOOTINGS
PLOT PLAN CHECKLIST 6. IC>
El PROPERTY LINES AND EASEMENTS 0 EXISTING!PROPOSED STRUCTURES ❑ EXISTING/PROPOSED OSS COMPONENTS AND LINES
❑ 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 0 NORTH ARROW 0 SCALE BAR
DIRECTIONS TO SITE AND SITE CONDITIONS:(ex locked gale)
OFFICIAL USE ONLY BELOW THIS LINE
UPGRADE/FAILURE SOURCE(for reporting purposes)
❑VOLUNTARY 0 MAINTENANCE/PUMPING ❑BUILDING PERMIT 0 HOME SALE ❑COMPLAINT ❑OTHER:
COMMENTS I CONDITIONS
Revision to 3bd
SEWAGE TANKS MUST BE LISTED UNDER DOH'LIST OF REGISTERED SEWAGE TANKS' TANKS MUST MEET CURRENT MINIMUM SIZE RE I t`r EIPE!D NH li
AND LIDS TO SURFACE,AND INCLUDE AN EFFLUENT FILTER(IF APPLICABLE) RECORD DRAWING AND INSTALLATION REPORT REQUIRE)UUUUUU R FINAL APPROVAL
INSPECTOR SIGNATURE DATE APPLICATION EXPIRATION DATE APPLICATION AR' ED/MADY7 2024
9/4/2025 R Thompson 20'4sr 09so P os7oc
By
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE ------REm3CO 12/704015
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