HomeMy WebLinkAboutSWG2025-00183 - SWG Application / Design - 5/19/2025 J L MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON:360-427-9670,EXT 400
BELFAIR:360-275-4467,EXT 400
..f� Public Health & Human Services ELMA:360-482-5269,EXT 400
FAX:360-427-7787
On-Site Sewage System Permit: SWG2025-00183
APPLICANT CHRIS ELSTROTT* Phone: 360-561-5000
Address: 128 NORTH RIVER STREET MONTESANO, WA 98563
APPLICANT Pinnacle Construction Phone: 360-780-3890
Address: 110 W K ST SUITE C SHELTON, WA 98584
OWNER WYBENGA CHARLOTTE L Phone:
Address: 4464 WEST STATE ROUTE 108 SHELTON, WA 98584
SEPTIC DESIGNER CHRIS ELLSTROTT Phone: 360-564-5000
Address: 128 N River ST MONTESANO, WA 98563
Site Address: 4464 W STATE ROUTE 108
Primary Parcel Number 419273200010
Permit Description: New 2bd pressure trench for additional dwelling
Permit Submitted Date: 05/19/2025
Permit Issued Date: 06/02/2025
Issued By: Rhonda Thompson
Current Permit Fees Paid: $555.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 05/30/2028 (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 Drain field 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.
OFFICIAL USE ONLY
MASON COUNTY DATE RECEIVED: 5/21/2025
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AMOUNT RECEIVED: RECEIVED BY'. cn
~: Public Health & Human Services $555 online CO m
Environmental Health 360-427-9670,ext.400 or 360-275-4467,ext.400
415 N.6th Street-Shelton,WA 98584
swG 2025 - 00183 0 73
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ON-SITE SEWAGE SYSTEM APPLICATION
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APPLICANT PHONE ITI
r
//nnA c% 4o/1s7Lr1-/G7%uri 3 60 - 780 -3e 9 D c
MAILING ADDRESS-STREET,CITY,STATE,ZIP CODE Cs
03
//i 4/ A". S7- s.—E• She/fa-1, w/ y °S / M
SITE ADDRESS-STREET,CITY,ZIP CODE f
el47/C 6/ w s.,e- /09 ; 5-4 GI r 9675--& V K
NAME OF DESIGNER PHONE
f —.760 - 5-6/- s_600 I N
NAME OF INSTALLER PHONE
O
PERMIT TYPE(select one) DRINKING WATER SOURCE ( IN
O
ffiRtglEENTIAL OSS fl COMMUNITY OSS FcommERCIAL OSSff-1RIVATE INDIVIDUAL WELL ❑ PRIVATE TWO-PARTY WELL Z Iv
Q PUBLIC WATER SYSTEM
TYPE OF WORK(select one)
h NEW CONSTRUCTION/UPGRADES L-C
REPAIR/REPLACEMENT OTHER DETAILS(select all/,at apply) ❑ TABLE X REPAIR 11,
SUBMITTALS ID SURFACING SEWAGE 0 EXISTING FAILURE 0 SHORELINE ca
DESIGN FORM(REQUIRED) _ EPTIC DESIGN(REQUIRED) BEDROOMS LOT SIZE WAS LOT CREATED AFTER 4/12025? r' IN
O I
5.WAIVER(S)(IF APPLICABLE) 2 y 97 0, , ❑ YES GI-11r 0
Xh,
DIRECTIONS TO SITE AND SITE CONDITIONS:lex.locked gate)
y4/6`/ if, Slz /Dg . .See- /�/c.,,, f,1 il'l rr o'‘ e-'�� r) ID
p0/w cf# -S2/o �.r y.v ,�.- ti s f-' 4�✓ .�/-=-101 —s ue /r /2d• p I o
6/w a/7 sR/Oe %r f r-".- , cis .7 Ao.--, vs ,rl4«V is I- (Ve, eta GA,-) IN
SITE MUST BE FLAGGED FROM MAIN ROAD AND TEST HOLES MUST BE FLAGGED WITH TEST HOLE NUMBERS. IC
OFFICIAL USE ONLY BELOW THIS LINE
UPGRADE/FAILURE SOURCE(for reportirg purposes)
❑VOLUNTARY ❑MAINTENANCE/PUMPING ❑BUILDING PERMIT CI HOME SALE ['COMPLAINT CI OTHER:
INSPECTOR SOIL LOGS COMMENTS/CONDITIONS
Both holes
0-72" LFS, 72+ bottom
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 DY DATE
c (1,\I„,eiveso,1 , 5/30/25 5/30/28 EH APPROVED
Rrcr4a Tt'ccpso,0E,02 2325
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE Revised:4/14/2025
DESIGN FORM-PAGE ONE Assessor's Parcel Number: 4 1 92 7-32-000 1 0
A design will be reviewed when 3 copies of each of the following are submitted:
`'Completed design form that has been signed and dated. ''Scaled layout sketch,including all applicable items on checklist.
`'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: 11"X 17"
PARCEL IDENTIFICATION
Permit Number: SWG 2025-00183 Designer's Name: ',/,e.-s /LG sTieo- -
Applicant's Name: /h/I('L/e �DnS7< Designer's Phone Number: �60 - s"6/- s' 'o o
Mailing Address: //D G✓ iC S,' ,(2r c.. Designer's Address: /2e a-" ///' 7c S T
S/ie/fo,., w/9 fecV City State Zip 71vooi77r7S-444' ,.f.,4es-a3
City State Zip Designer's Email e/s74?-o i ==. gal- -o.*7
DESIGN PARAMETERS
Treatment Device
❑ Glendon ❑ Sand Filter 0 Mound 0 Sand Lined Drainfield 0 Recirculating Filter 0 ATU L1 Other
Treatment Level(check all that apply): 0 A 0 B ❑C 0 BLI C BL2 0 BL3 F E ❑N 60,v eicr, G osj-
infield Type
❑Gravity ressure Fat 4r:ch ❑Bed 0 Sub Surface Drip
Septic Tank/Drainfield Specifications Laterals
Number of Bedrooms .2.. Schedule/Class 4/0
Daily Flow:Operating Capacity / gpd Length y S ft
Daily Flow:Design Flow 2 ' ' gpd Diameter //y in
Septic Tank Capacity(working) /2..e. o gal Number ,2
Receiving Soil Type(1-6) 5( Separation /p ft
Receiving Soil Appl.Rate c3,6 gpd/ft2 Orifices
Required Primary Area S/Gto ft2 Total Number of Orifices
Designed Primary Area WC- ft2 Diameter .2//6 '' in
Designed Reserve Area Yar ft2 Spacing 36 in
Trench/Bed Width 3' ft Manifold
Tre Bed Length yS' ft chedule/Class yo
Elevation Measurements Length Z. ft
Original Drainfield Area Slope 8 % Diameter 2 ' in
New Slope, If Altered 9 % Preferred manifold configuration used? ❑Yes 0 No
Depth of Excavation Up-slope F0 in Transport Pipe
from Original Grade Down-Slope 2 7 in Schedule/Class yo
Designed Vertical Separation ,3‘1- in Length 75' ft
Gravel-based Drainfield Required? 0 Yes 0'S' Diameter Z in
Pump Required? 0 No Dosing and Pump Chamber
Pump/Siphon Specifications Number of doses/day .?
Diff.in Elevation Between Pump&Uppermost Orifice /2-- 11 Dose quantity ,gip gal
Drainfield Squirt Height/ei/Selected Residual (head) f ft Chamber Capacity(flood) /y.pp gal
Uppermost Orifice L7 Higher CILower than Pump Shutoff imp control : Please check
Capacity those required. ��
Capacity @ Total Pressure Head 5/2. gpm la imer tt'>;la those
Meter C1'Event Counter
Calculated Total Precgure Head 2,' ft If Tinier: Pump on .) e?� 1- ,Pump off
Comments AY /N✓7A4[4417O4/
EH APPROVED
Rhonda Thompson 06/02/2025
Revised:4/14/2025
DESIGN FORM —PAGE TWO Assessor's Parcel Number: 41927-32-00010
Permit Number: SWG 2025-00183
DESIGN CHECKLISTS
Scale lot Plan Scaled ayout Sketch Cross-Section Sketch
Test hole locations Dinfreld orientation and layout Reference th from original grade:
EVS111-logs a'—Trench/bed dimensions and S�eptis tank
CY.ro lines 40x/Valve' cal distances within layout [7�brainfield cover
F.xisting and proposed wells � hnx locations Reference depth from original grade
wit in 100 ft of property [ • Septic tank/pump chamber and restric ' e strata:
[IYMeasurements to cuts,banks,and ig.r.etions p'Laterals,trench bed,top and
s e water and critical areasQ Orvation port location bottom
!ellINLocation and orientation of l Cl -out location Curtain ' collector
6a'Ea4»-elrain and all absorption fold placement ❑ Cation
co onents a�l�l ce placement Other cross-section detail:
❑'Location and dimension of C- Lateral placement with distance 0 Observation ports/clean-outs
pn ary system and reserve area to a of bed
�g Other Information
al-Bui ings ❑----A e/visual alarm referenced Yes No
❑ 41 ion of slope indicator
0---Scale of drawing shown on scale ❑ ❑Design staked out
l� a��terlines bar 0 l 1 ecorded Notices attached
❑.loads,easements,driveways, levation benchmark and relative D aiaiver(s)attached
par g elevations of system components (9 �D P curve attached
CYNorth arrow and scale drawing 06aluation of failure
shown on scale bar Non-residential justification
❑ 0 W e strength
-low
DESIGN APPROVAL
The undersigned designer must be notified by installer at time of installation Ees 0 No
Sigma ure of Designer Date
The undersigned has reviewed this design on behalf of Mason County Public Health and determined it to be in
compliance with state and local on-site regulations:
)cl(keyyym6
0•-1/L 6/2/25
Environmental Health Specialist Date
CAUTION: DESIGN APPROVAL IS VALID ONLY UNDER THE FOLLOWING CONDITION:
✓ The design is stamped"Approved"by Mason County Public Health. 5/30/28
V The Onsite Sewage Permit has not expired,the Permit Expiration Date is:
✓ 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.
An Installation Fee is required.
This form may be scanned and available for public view on the Mason County Web site. Revised:4/14/2025
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