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HomeMy WebLinkAboutSWG95-00212 - SWG Application / Design / As-Built - 4/12/1995 : IIIIIIIIIIIIIIIIIIWIIPMFIIIIIIIIIIIIIEo_, E MASON COUNTY DEPARTMENT OF HEALTH SERVICES ++ a Date lr .. l g• 8 426 W.CEDAR/P.O.BOX 1666/SHELTON,WA 98584 ���, s�� � PHONE(360)427-9670 Amount E_I�� r� Z m PRO O : DM I: CHECK APPUCABLE ITEMS ✓ �(( .., - L [s ''� - - NEW sYSTEM V m MAIL Al/DR SS DAYlI E ONE: NEWSYST5TEM CITYo $Qx_1Z _ ,2}6-SLLg REVIEW STATE: Q ZIP: SINGLE FAMILY _ V . Alta �a. 185� OTHER Z PROPERTY ADDRESS: SPECIFY: e Ill p11✓ ?tilt- SPECIE WELL SPECIFIC DIRECTIONS FOR L ATING SITE: Cp1pdUNRYYVELL1PlJ8UCSYSTEM ✓ N Cbt11Ns �.IL OR -►n LAST" FORD on) -STD [Rtt_ SYSTEM WFIa n Q��cF - SYSTEM NAME(1s IY 11t0 Iv -xcauO TD� - -a/,.J nrJ UPI MAAtsei 1.41 fi— APPUCANI etssooS N Iv • = MAEING ADDRESS I w Name of Lot 1/2S h.x o Installer �_'t acres TELEPHONE 0 is - z. I- SIGNATU Name of umber of Designer ' j; Bedrooms X 14.) � PLOT PLAN H Draw nat plot IQU, 5 S w Includi((mi�l LL! R b O Prede�iri of testy ' t Lq/y SI IQ h°��^r darts > SO 7 ErJ mew Dist s toW e- - - - p.g.c._ 41 pronoun s. W / r L7� 4 k f I� O Ent ;ettt�raads� ��'r G3 IW �� t1 NOTEMNOfHAW,jpIJ s L j TyS EM DES/ r Its-yR .....-----A OFFICIAL USE ONLY.DO NOT W BELOW DOUBLE LINE. __ - LOGS Tti I 0-5IA 11 r74/e/51-"- zwib ky,,„ ,„4 ,x.„, skz2.,s, u 4 0‘.31t 0 .5 .'I revel /S a l9 .5 436a saitr- G 7t471 5 6-3o " R9 ia -riii - crobkier ta5 /,/.,/�) /� ,c3 ,r/ Depth from Orig nal 1 /" C%r l�c �� "/ Grade to Restrictive cap oil i q�<d se Layer or Water Table: J tiJ In. DESIGNER DESIGNATION SCORES MINIMUM STEM REOUIREMEt1ITS -- Designer Level: :1 Ore Two Finding� Score 1 Soil Type y $split Tank) Daily6 Capacity:/` Q �l/D GAD Vertical Separation `�� n. Gal. Flow: %Dee a,-�� _ Appl. Infilt. Parcel Size /, 3/ Ac _O___. Rate Q,G CPO/FT, Area( Fr' l / Distance to Shoreline WA n 13 - Tota�! In Date spec J 7/076-0n 7/9 C. rc C. ORION- FOR APPROVAL S/ G� lam' I/i.J Ai t / • . I J, /ii ,I (� ��1 c- P77:7.{/'O /777 /i?, 0 r7 k1 E71142 .taJ( [:l5�rtl_ , / •-•- mi 11 /• '// :• ' •.�i! •..4. : fI<.I'/rTwir/ I! - �%a•- a. . ' IILIMITS • approval is oertifi= by Mason County Department of Hea i Services,unless prior •All septic systems must be de :fed and installed by contractors granted by the department,or the design is by a professional engineer. •Septic permit approval does not imply other building site requirements(i.e.RLC,Water Adequacy)have beer met. •Any change from the specified use of the property or any site alteration affecting the system design may invabdate this permit. This Permit y,..res 2 years from dale of site Inspection.Den of thls• 1 ma be • aled to the Health Officer whin 10 ay of denial date. SITE IE DE Approved J Not •••r0 .• INS TT 11 . / BY: t A DATE: BY:��ii%►I II :I DATE:a Not / iS BY: 1 i , ,� rid Ai 1� �•� ww 9 f* t s Copy f� 70P:Health Dept.Copy 4 IDDLE:Designers Copy 80 OM:App,� 20 • JUt l 08 '95. 14:22 BENIK 360 692-5600 P.2i 10 U IOI{M- PAGE:ONE IN.(410 A Revised 08/94/91 41C4iiSign . ili .be reviewed whia ,3 posies of each of the for • og items are submitted! ..: Completed design form that has been' signed and •. ed • I Completed Resource Lands and Critical Areas Checklist attached i•. Scaled plot plant including all applicable items on checklist • .Scaled layout sk toh, including all applicable items on checklist Cross-section sk tch, including all applicable items on checklist F , ; . PARCEL IDENTIFICATION 1 , Permit Nuabeir Sw< 9$-O4.)Z Designer's Name - C.a,t N Ua.iis 1)14: �s f Applicant's Name jC C,h,A. yt Prop.. Owner's Name ... '^'iS- AS .Afftje_#,I.kr Mailing Address i,, t Mailing Address I F*: 19, - 1 City � state Zip city stet zip Assessor's Parcel. No. Z7-S31-5t car.O; z- Subdivision C tt�...,5 ,� +- .1�� LeT 1 : txweive-u git Number) F�IaibtitTlkltiy o4t cHbaRfgt ttts)t1 • — PVh -- DESIGN PARAMETERS Initials / J Date --�g4 / � J 6___j____ i 4' 1 I Designed Vertical i H I L separation Mound subsurface Pressure Gravity Bed Trench s!Y A`I ' in i Septic Tarik/Drainfiald Snaciff.cations No. Bedrooms : i r Pressure Distribution? ;'��, Yes 0 No Daily Flow : 1(,d qp4 sun:uu..,: (If yes, proceed. . .) ii3i6iit::anni Septic Tank dapeoity h t oak Receiving Soil Type (1-6) II Receiving Soil. Appl. Rate 1•t- g;Pd/ft' Laterals .l .� Trench/Bed Bottom Area i/oca ft2 Schedule/Class Sutp `to Trench/Bed Width. i 3 ft Length SS.T ft Trench/Bed 'Length ; ?ace ft Diameter l° Blevetion Measurements Number Is Orig. Drainlield.Asea Slope ! t Separation-- n1,N1..�-"-'- (d LOA .In Final Drainf J.eld Area Slope r IT'. t Orifices Etc- Depth of Bottom of Trench/Bed r4-. Total Number of Orifices P. from Ori ina grade ' g � 8' Diameter �, Spacing .2. manifold . '"ns Schedule/Class 1 Length etc Infiltrator Used?' 0 Yep PB No Diameter " ` Transport Pipe Pump Reciuired? W Yew 0 No Schedule/Class '149 : • (if yes, proceed: . .) 3 s:::::u:: diM Length .± Diameter ' " Pump/eiphon.6pecitioations Dosing and Pump Chambe Difference in.,Elevation Between Pump Shutoff ft Doses/Day and Uppermost:Orifice + (a' ft Dose Quantity j Chamber Capacity , (rr�a• Uppermost orifice is to higher, IIE]lgwer. than Pump Shutoff � ✓ I Check the following components if they drain Capacity • Tot . 'Pres. Head A. 6 between doses: • S/g;tm `v+oE Nor tow Calculated Tot. Pres, Head 5•7- (Attach Pump Laterals Manifold 0 Transport I y • juts, es '95 14:23 BENIK *:,0 692-5600 P.3i10 11 . , • 11 /I)IISAGNJJORM — PAGE TWO R.v,..d o rill'_...::., _ . DESIf1N Ct1ECXLISTB 11 $c.$led Plot Plan Scaled Levaut Sketch Croaa-Section ak.b 1 r Reference dopth from orig- 3est hole locations tr urainfield orientation final grade] Ic� and layout lroperty lines 'Septic tank lid and ET- 1'xenvtl/bad dimensions and drainfield cover depth of ng and proposed critical distances within Ir- well Within 100 ft layout Reference depth from orig- inal of property lines l inal grade and restrictive 1/ { / f-J D-Box/"T"/"L" locations strata: p Ci Critical distance measurements to cuts, Septic tank/pump chamber 1 Laterals, trench/bed 1 banks, surface water i location top and bottom ILocation and orientation! observation port location Curt in drain collector II of curtain drain and all �y 11 abso>rption area �Cleanout location U Sand auyimentation 1 `- components reference No external j'r i- Manifold placementneeded:I (! L9catiLon and dimension r�� '� of primary system and I rifice placement �/ObHervation ports and I 1,1 ► J O I reserve area 1 cleanouls �� B. Lateral placement, with �--J Buildings diotenyo a Lai eU1ye ur pea Addition mound inforaatioat I CO- Direction of elope U Audible/visual alarm U Upslo a and downslope I. ('indicator referenced fill width i '--+ waterlinesScale of drawingshown U • Settled cap depth at �Rj on scale bar center and edge of bed 1 oadeAeasements/ drivel ys/parking Additions hound Information: ID Sidewall slope 014. 0 p CErcri&OUI reaource landa k 0 Bndelope width 0 Up/downelope bed elevat. 1 (if applicable) ii j 0 Overall fill dimensions Completed Resource Lands and North farrow and scale of j y�ritt�i Aram, Obenk .st ! drawing shown on bar lli �._ . , It d 1 DESIGN APPROVAL II .-- - - - m • mil II • i-l I IThe undersigned designer -!Sloes, does not, waive the regir•emant to b. notified by the installer of the installation and given 48 hours to perform a final inspection prior to 1 cover. p H 3 S l �DaCB I II The: underei ned has revie3 R I< S ppr d is design on behalf(of Naeo County of Health II Services. v P�g5 ns a I� j H .. CAUTION: THIS DESIGN IS ONLY b IP STAMPED "APPROVED' BY M1tSON CO. DEPT. or HEALTH H ft a -.., .. J i JUN 0$ '95 14:24 BENIK i60 692-5600 P.4/10 r. • • • 13 • • : • i , ! t 1 .• , V, :st ' / : ,--- • • a , i.: .,. . • • ;i • i ; • i .. - fl 1 .- it •i t` • i ° Mason County pt. Heatth ' !?e Services ' o -� • ; t APPROVED ��� f it . . . ' ! • i ' tnitiats V» r` •. v g 1 d / Date 11, e C. 1 / e . t I—, . : / • .. . ...______... . ... _ . . ......... ................... . ---- — -- - • 1 . I 1 1 I 14 i . . . , r— I .. . .. 1 .It' • I • • -.1 ! 1... • .:. / . • - , .. - ir . • ; ' / • ' t T s ot .1. i .. • .: I. 1 • . . . • :2 . ... ; N. • • . • . t t... ... :., . . e • . eo!S .• 1: i il. ,f1:1.' ..; .;;;1-. Pi.. •• . i . • . I I ki • / : i I .• • • . • i 71 3. , • :• . • i . . 1A1 • I.: i 41 • '' . . 1 •I 'i .....).• . 1 I f$1 I :', i 16 --, 5 " • a.. t' a l •i : • : 1 ki 1 ti . • 1 .1.--• fi .• .1 1: - •: •:1 ii[ : ; • ti-f•I ..!...4• . . '. • •* ''' . ..... .,. o• •; .. a ' el 'b •• • ' • S ie ......:.„, S 41 v• ...., i .. r4-1.,-,; . • % is a 7 6. • 1 zi.7,.. .t.i: i. 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't V• / i t G. *4 :.,t .4. • 41. t . i 't•'.'i ' '. 4• •••E 1 ...•••k • - . i i • :rit • - :w ` 14J V Iwr`.� W � ' y . 1. ) 47 } •.,r !' . ... . u * fj o • I I a JQQQ�...i I m ✓ ' ; j •1 . r I 0 • . • • r , i. , I 1 , Y. ' --- Q I• , a . • c",s. • Y, 1 1 ..):..6:: 6, : J . . .. ..... .; . . ........; I ,a ., .,:e: # 0 , N . • i .1'' '• : 1: : i 3 rt,4, -74: , . • . g, ita j •;•• . . ' . • . I \ i," • f • I . r : 1. • :.. ,, ,. ., r .. i LL . 4 . , . . . . .'. .a 4•1/43 4 : ! . shi • . ft< • : • ° . . • .. I I 1 C ; I a+ a j . z l ' C , a 1 i i • i ( 1 . 0T/9'd 009S-269 09E NIN31 SE:PT S6. 90 441r• , JUN 08 '95 14=26 BFIVIK 360 692-5600 P.7/10 FIGURE 6-3 4 { I!TYPICAL TWO-COMPARTMENT SEPTIC TANK I i ifiliiiiiiiiiiiiiiiffiliMill- - • 4 • lip b�i� a1 ti I , 1 1 1 • I. 7 1.--1I Access ,I--III . fit.• 1 Manholes ""� 1 I ' l l .i .Plan I i , ••S.au►tary -�_._.__. F,..4s. D 42,._aa Tee ' t — ._._-____.Vent. . le. ..._L-1 . .. Inlet ---i .;r Liquid Levet pullet i . j • . J Longitudinal Section I. I Mason County Bept, Health c' Dery ces PROS D Initials 108 Date �� i JUN 0B.. '95 14:26 HENIK 360 692-5600 _ P.8/10 . D itti V PEfIQIfs P. .awl 2954 SIIUE IIHIL E,W 19$303 pf...1216)692-3993. 1. , ' FAH'12U1692-5619 LICENK11,11N 511E SI1lWffIVEUISP4f1.:CONSIfl nNI..rLnCtOLfTIUNtEsts nNU ENSINEEf1M1o.9E1l4941 SUREDATA SHEET i 1.) :Pip. Minimum .Claw 2 o q • ' 2.) Orifice Size=• 12/.V' • i I. • 3.4•. SPadng'i •"....1.• . • 4.) 'i Lat.ral Sits*/ i I j + ' S.) Cet tir Manifold - t dare) :Mapimum Length - _ .5: • . a . End 1 nifold �- Lateral Maldmum Length .._ _:- . • . • 6) • V&Ye ill Lai ,Laterals 7:) Ch. Yalu.Ru juWexi.s. en.Laterals on Manifold • :. , ' . .8.) Mai ld Diameter Size . Lei'--- ' ' 9.1 Mantfpoid••Maximam Length - 40 t_ •t 10.) Mfx m Trasport .Dleter 'Six* ...... . ' . .. ' . 11.) :Mpximum Trenleport• Lin+ Length - __ 21 . r t• i S v. •12.)' Mud Put `K� gallmin at',Total Head of -' . 13.)0.1,,u R..idtsal jleidR ed • is ash 14.y ,POrnl Alarm •R;rquired( Te. and visual) Co /, : 16.) .SA Tank Fltt.r Aequ El •. ' p ./1 j ,kte.s. 1.8..), : Dr.infieldl a Mini of t Times Daily 4&2!;:`44--, : . 1. �i'� 111 ate 17.) Siel%ny Add�ad oesi4ers;Notes •• ill:) 45'I Cleanout pt and of: lateral - marked with re* or metal tape ? • . I MIIL. --. I . . N. .1 I . . ix., 1 . . . . . II Di -.. .i.' : ...... .._. •. . .: .1..., lit .i 1 I ti 1 .e• a.- 11 . , . 11 1. . . • .1. 1 . '.. P . 3 . .. • - & 0? -. • ii Bi k ./ 4 - • ralli. • . . . . 1.1 LI 96 II 1.i;.1. • :11 i il• .: . : 4 )4 ..1 i il ./5/t /J . r' I: . . :, 2 .5 i kiL if R • i 1 1 • 41 Ilik, . . g . : ..! .I) 11 12 .1 g g • gl- k Lir: H.041i I .O. 1 III! 0. .i... !: 4 NJ - 1. .. • 1 g 2 "I ' . • - . . ..V •4.. . . .- •P . • .. ., : .: I .• - , •• . ' . • ** 'eS • .: . . t/' ' • • " ' . .. , ,, ' • • • - 1 r''',+^ ' .3. • • '. .°""•T,-‘1,a.rk.• . 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I . : .. , •2 - ':',' . :,:i.:1::.t%.:%ii..: . : I' i . 4 ,. • • • .;...t.:„. ...te., . . :,:,..i• .i.,....:, 1 . • ti:::::,. . -...y..1•::?v.;..% • • ° • : .:•'!:,..• 1 1, -1 t. • -.'':.: • •• . • - . . 1:z•-..7:-;1-.!.;!.'-.:"..Lie ''.,•••;:i....' . , .. ..; ,.....r .. . . 1 tl• .- •.'. • , .... ,.....g .,,, • ,•. 1 . ...":: h •. . • . •••.•• - :-...•::!::17:i il.7:••ilZ: ..:...',, i :: LI'..•'i•4,-4:- '•;. ,4' ' I • • 111 1 1 . I IMO z., c:i..T.'•::.,I.&*-4!•`21:'. -. ' • • • ",,.r.' law 1.II - , , ,•%:,4 t;,, ,42.410-2.1s : ,,. vim- .•. - ` "" ''', — ' ...:• ; ".— . ',-‘..i..-; --- ' 1%,.... I:: . . . ••• ., ,. „ . . . 41..7...p.o.) • 111 • -. ., : I . . 0 k . I _ • • .. .. • , • 009S-269 04 All+1311 1.2:tt S64 ES Nu • eT/6•ci • ON-SITE SEWAGE INSTALLATION FINAL INSPECTION DATE CALLED IN: \q.c TIME: O1 a� —�=�5-`=-•�-�'� INSTALLER: APPLICANT/OWNER: ��`1-\ q t i \L CALLER: _. �- dS7\k� � Q -• PHONE it OF CALLER: L1 h /L, _ SWG #: qsr-ca. Q. 4, ") PARCEL NUMBER: VJ SUBDIVISION: IDS "u DIVISION: LOT: •.• HH•i•:: :::::».w.N•.u•.wH•N.....•••••Nw•M•.••M••.•...•.••••»ww•w NN••N• w •• .NNw NY • .. •..w N NN•N• ••••.•wM» u..•.N•.NwN..wN•uuNwHN•NNNNN.»NNNw N•NNN••......w.•.NNN• w.•.•• SYSTEM TYPE (CHECK ONE) : a • �f INSPECTION SCHEDULE (CHECK ONE) l_J y� ANENTPLUG IN (`/Xl) U AS-BUILT ON-SITE? (CHECK ONE) : NO STAFF INITIALS: h:callin.w Revised 02/01/95 ON-SITE SEWAGE INSTALLATION STAFF INSPECTION REPORT trArs C1 Scl1.IST COHITR?ED BY ZHSPiCTOR) Z. SAPTIC TANK Y a No Caawata a) >5 ft from foundation? a) Bldg stubout to septic tank: cleanaut if not 1-2X? c) Baffles intact and clean? .r _ n) Dividing wall intact? U. n-soa Leveled with ester or speed leveler (circle one)? 0 :' zzz. DaatNTLELo a) >10 ft from foundation and >5 ft from property lines? a) Laterals level to s1 inch i end ups present if not looped? c) System dimensions the same as shorn on the design? a) Gravel clean, properly sized, and proper depth? a) PIZSSUSZ arms zI Sand quality AS171 C 337 f 2) Heed height uniform and 1:24 inches? 3) Clcanouts and observation ports present? a) Mound: Side slope 3:17 s) Owner inforeed electrical connections must be mode by owner or licensed electrician and inspected by DLT? 29. POTAALA l AIN= a. >10ft from drain tield, transport line, and septic tank? a) Neils >100ft from drainfietd7 V. raw TANK • a) Screen basket or noes? fi (circle one) installed? a) Riser installed for c) Alarm installed? vs. At IUU.T xsCozssa? \ --- WI. OTNNA aolomri i The undersigned has reviewed this installation verifi t on behalf of Mason County of Health Services. lie nspector h:callin_w Revised 02/01/95 Ammommommw AS-BUILT FORM - PAGE ONE Revised 12/14/94 II �J PARCEL IDENTIFICATION II I" F �ifZIF2 — — II Applicant's Name eaC N ,� i Permit Number SWG9� - 0�i a Subdivision � ��/�'V II 4 /.— ion o lI Installer's NameAr S Q/t/l Assessor's Parcel No. i? 33 t S.i OC.Y�?.Z{I Designer's Name Q14/t�s 's'�A+s ll Ij INSTALLER CHECKLIST 1 N/A Yes Prior to I I. SEPTIC TANK Completion I A) >5 ft from foundation? — B) Bldg stubout to septic tank: cleanout if not 1-2t? l — C) Baffles intact and clean? I D) Dividing wall intact? II — II. D-BOX Leveled with water and/or speed leveler (circle)? III. DRAINFIELD A) >10 ft from foundation and >5 ft from property lines? — X — 0 B) Laterals level to tl inch & end caps present if not looped? — — C) System dimensions the same as shown on the design? — lk — D) Gravel clean, properly sized, and proper depth? — E) PRESSURE SYSTEM 1) Sand quality ASTM C-33? 2) Head height uniform and x24 inches? — 3) Cleanouts and observation ports present? — li 4) Mound: Side slope 3:1? — 5) Owner informed electrical connections must be made by 0 owner or licensed electrician and inspected by DLI? — -K. — II IV. POTABLE WATER LINES II A) >loft from drainfield? — X = N B) Wells >100ft from drainfield? — V. PUMP/POMP CHAMBER f A) Designed pump used, or spec tached for equivalent pump? � X., E B) screen basket or luen filte (circle one) installed? — C) Riser installed for access? I D) Alarm installed? —_ 1 CERTIFICATION OF INSTALLATION q installer: check box from Row 'A,' check box from Row 'B,' sign and date the certification. A.0 1 certify that I installed the system I certify that all deviations from without any deviation from the design the design stamped •APPROVED" by MCaHB are 1 I stamped "APPROVED" by MCDHS. shown on the reverse side of this form. bB.J�-- I certify that I contacted the 0 I did not contact the designer prior N designer and left the system open for to final cover because the designer jl (I inspection up to 48 hrs prior to cover. waived the notification requirement. q I further certify that all information contained on this form is accurate. I understand 0 that if the information[ contained:herein' is not a• ate,' there•will-be Just:cau$e 'fvr . 1 •. immediate suspension of my ins er cer cat 5z e o ! /� 1 . 7s— II The undersigned approves t 's stall 'on •f • half of Mason C t Department of Health q 11 II Services. i II 5 II heals i r - t e� II II a AS-BUILT FORM - PAGE TWO Revi"ad 12/14/94-_- — _ ,, II PARCEL IDENTIFICATION II Il It t II Applicant's Name II II Subdivision 47,,,...„ ?v' ) w ,,Permit Number SWG9 aivisi n,���tflOCcx/Lo II h Installer's Name fl..1 n� ' Assessor's Parcel No. t=� � G;eaDO 1.0 II Designer's Name RLFS �a Sr �S " I' tl IItI AS-BUILT DRAWING II I i II II 0 G i II _ II j i • �� Il . I s' I II 0 Ij k Moir/ II I\� -F G I oP� R II II II ® CIFfir: II " II Ii H , o.I II H I II E4t240y- i ve GvR� II 11 _._ tI 11 cwrio 7, Minor adjustments to septic tank location and drainfleld orientation made in the field by the installer are generally atc- he ceptable to both the department and the designer, but could In certain cases compromise the viability of the sys installer's respoaslbility to obtain prior written Appwovila from either the health d partment or the designer before making any tea viability. Any deviations fro. the approved design moat be slow above. deviations from the design that affect aye — p h AS-BUILT CHECKLIST II Drainfield orientation �l Observation port location Undisturbed native soil 11 II between trenches II p and layout Cleanout location II p�1 North arrow HI p4-Trench/bed dimensions and II critical distances within Manifold placement Scale of drawing shown a 11 layout Orifice placement on scale bar II I) g D-Box/"T"/"L" location 11 I I 0 Lateral placement, with ,Additional Mound Information li II l Septic tank/pump chamber distances to edge of bed 1 il location Endslope width II 11 Location of wells, roads u Overall fill dimensions II II ! Location of buildings 11 r �'(L J ' • ON-SITE SEWAGE SYSTEM SURVEY LOWER HOOD CANAL CLEAN WATER DISTRICT M Tana a Nt OProject LLIC Area: ` Date: OWNER INFORMATION : ce"N. aki2A ced•P' Owner's Phone: I5 -3—‘4 /12E /1I leaLk. r Y 1222 Y �'o l CIA S L& ce. g 2 v 3 2 5-e.1 r CAM q-552 u SITE INFORMATION : )33 Parcel# : ` 4-3 ( — S -- C)O O 3 2- Well Depth: Address: n F I 11 e 4 fee. P( City: r State: WA Zip: Building Type: F (F-wu rem Residence; S -Seasonal; C -Commercial; M -Muki-family; V -vacant) Septic System Type: S (S - standard tank and drtinfietd; P- Pressure niatrtbuion; F- s.n i Pater; M- Mound; T- Deep Trench; A--out House; O other; U -Unknown) Installation Date: S Year Last Pumped: ) 9 r 5 (Bent Yse,or U-unknown) © System Location: (F-Prod Yeti; B-Beek Yard; S -silo Yard; A - Adjacent Lot;U- Unknown) Number of Residents: 2 Shoreline (<100 feet from Marine oc Fresh Water) (Y/N) OCCUPANT INFORMATION(ootmpicte only if differed thin owOer): Occupant's Title: (MR, MRs, Ms)First Name: Last Name: Occupant's Phone: Would you like Information on Water Conservation? (YIN) Would you be interested in a Community Workshop? (YIN) PERMISSION FOR ACCESS TO INSPECT E SEPTIC SYSTEM: t/ IN) SIGNATURE: Date: g3i/Ps Comments: Revised lure 29,1994 ,.., ., . . .., -+ .1 . it.4 Cr • drit x• of 1 • ti it r fillii 1, S 1 I tiefilvj uAleo'-)f--) . .._ _ , ______ __, _ _ ,,, .,,,,__.„ fa,,,,..„ -. S 11116 4 • .• :LOWER HOOD CANAL FIELD INSPECTION FORM co) InitialInformation: • Area: /f T :1/t Added to databa:e(Y/N): Owner Name: rt., "i/knt..- Permission to Inspect?: Site Address: Ne I,t hm.iyet Appointment Required?: Parcel#: Z Z 3 3 i- S+-ow 31/31 Appointment Date: Occupant Name: Inspections: Level 1: /9/1.7/4S Level 1C: ( I I ( L Level 2: Inspection Team: 111`01 Updated database(Y/N): Inspection Results: Distance between septic tank and surface water. i OO (ft) Distance between septic tank and well: c..w►M. Distance between drainfield and surface water: t d U+ (ft) Distance between drainfield and well: coo... (ft) Ocaipancy(occupants/bedrooms): L/Z. Other(Larger on-site,businecs..etc...): ✓The septic system appeared to be functioning at the time of the inspection; no obvious problans were observed. The drainfield area may be compromised due to vehicular traffic. (i.e.: parking,driving) There are indications of poor system maintenance. (i.e.:lack of re:guts-pumping,inky ibhmbing,slow drains,eaceessive chemical dumping,high water usage) Construction was noted in the drainfield area. Sewage was observed entering surface water;confirmed by visual dye and fecal coliform — Count of>200fd100m1. iAa unpermitted outhouse was observed. —Other: Ottbx: • A�dGdj Comment*: ,/ Q� �(/ d�i� o AViaIIMe Avtra pv0,4 Ul�A4..I ':.I .24-(e'� SV1% System Classification: Pass: 1/ Pail: Suspect: Failure Priority: end Way wild.x vine!Dye et"Waft eewis,��i adios War...c MOM rt! � <It Volt.I .sm. W.k'Mdaii mobs Add sitid sW slier./:Oi r ww4M itWrnC ice■+ vim waft O .saes irrr.S: (WO • • j • • Ai 44eIP% Ji e ,fry41, )i`lea- ialuilIN• - r10.444.31t . • i}k.• ' der-at;, ., r• - r�ii1 • i• It WTI ks r, .A of .1 7(iQ • Legit ;0001itt.o. rassi 4,1444, _ = . • • rnfsys:* • ..n ,. tare . r 13. . Lii ,p .6 .: ,. r 4. "PIA" 1 • a• • t,/ iUi Av4.t 1 �"•l�t. WET IOU- ._1,4 , 11 WWII*ups wt�ii wilier(t wy IRS "_Apt ., .�.....���ti �! ' UMW aAa 01.4r). • • • . ,•., Y•.., . . ..._......s.......-//7 'fif7r.--"*"-••••.„........\\. ,,.."--...) C V .(4!I ik...____../ . II. . ,...14 I. _��-... �.. r. ., fr • , . cin . : , ~ • ,. ., Ci. , •,.......„.".....: • ____.----: r,-,44 • SVIQ / _-:i;fiiu , .4 . ON-SITE SEWAGE SYSTEM SURVEY LOWER HOOD CANAL CLEAN WATER DISTRICT Project: LEG Area: I I Lo ovve r v, t 1't • Date: OWNER INFORMATION: po Tot 12Z2 , WA 4q62S SITE INFORMATION: c tjLL\iW S L4W" 2 T2 3 3 Parcel# : 2 2 5 (-S I- 00O 5 3 Owner's Phone: Address: Y(E f ! P r e e ` i may: State: _NA_ Tap. Building Type: -' (F-PUS Time Residence; S - Seasonal Residence; C -Commercial; M -'Multi-famly Residence; Y-Vacant) Septic System,Type: P (S -Standard tank sad d Ufad; P-Pressure D;straluition; F- Sand ; M-Mouth; T-Deep Trench; H- oat Howe; O -Other; U-vim) Inct lbttion Date: Cl I Year Last Pumper!: (Bruer Year or U- Unknown) ) System Location: S (F Front Yard; B -Back Yard; S-Side Yard; A-Mjaesot Lot; U vi wn) Number of Residents: t Shoreline(YIN): OCCUPANT INFORMATION(complete cdy if diclimot dam o ): • Occupant's Title: (na. sas, rss)First Name: Last Name: Occupant's Phone: Would you like Information on Water Conservation? (Y ) Would you be interested in a Community Workshop? ('YIN) • PERMISSION FOR ACCESS TO INSPECT THE SEPTIC SYSTEM (YEN) SIGNATURE: V P/v i o v, l-)7 0 wo.e..r- Date; ' Comments: • LOWER HOOD CANAL FIELD INSPECTION FORM Initial Information: • Area: 1 1 i o a✓1 eS ch I I-e Added to database(Y/N): v1 Owner Name: y« .co•( K'M,t r- Permission to Inspect?: Site Address: ,1lr +1 I P ie Tit p( Appointment Required?: v1 Parcel#: Z331 —S I— 0 o vS Appointment Date: Occupant Name: Inspections: Level 1: t I 14 I Level 1C: I if 't C. Level 2: Inspection Team Updated database(Y/N): Inspedioa Results: Distance between septic tank and surface water: I ovt (ft) Distance between septic tank and well: C o"A" (8) Distance between drainfield and surface water: t c.v* (ft) Distance between drainfield and well: Occupancy(occupants/bedrooms): 14I Z- Other(Larger on-site,business..etc...): Vibe septic system appeared to be functioning at the time of the inspection; no obvious problems were observed. The drainfield area may be compromised due to vehicular traffic.(i.e.:parking, driving) There are indications of poor system maintenance. (Le.:lack of regular pumping, leaky plumbing,slow drains,excessive chemical dumping,high water usage) Construction was noted in the drainfield area. Sewage was observed entering surface water,confirmed by visual dye and fecal coliform count of>200fr/100mL An unpermitted outhouse was observed. Other: Additional Comments: ►^ t i f S System Qassillcation: Pass: �/ Fail: Suspect: Failure Priority: Mortis 1: am iee0 nleeel.x Viwt Dye.era R prise*emir ewe*=foe mire,wit homes or awooh <3R Vat_let.from O WW.3: Irdrcir!earl[dent not wart mhos wow.4:Other yeeragriie iemaadaarg moms mot cow* mhos War.3:Moray malk6e4 Odor) 1.111111....11111, SITE DIAGRAM DYE PACKET RESULTS Backpaead cries 1 Retrieval save 2 Retrieval Swim 3 Retrieval Sic Nrebar Dete Dale Rabbi Dale Data Recall, Placed RsDab Raab Data 13ade Plead Retrieve Ranks Mold Retrieve Placed Retrieve 0 BACTERIOLOGICAL RESULTS Site Date Results Number Q e