HomeMy WebLinkAboutSWG2025-00241 - SWG Application / As-Built - 6/23/2025 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON:360-427-9670,EXT 400
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: SWG2025-00241
OWNER ANDERSON BRADLEY T & HILLARY A Phone:
Address: 2420 NE BOULDERSTONE CT POULSBO, WA 98370
APPLICANT ANDERSON BRADLEY T & HILLARY A Phone:
Address: 2420 NE BOULDERSTONE CT POULSBO, WA 98370
SEPTIC DESIGNER BOB PAYSSE* Phone: 360-507-1498
Address: 3083 E Mason Benson Road GRAPEVIEW, WA 98546
SEPTIC INSTALLER TBD Phone:
Address: 123 XXX XX, XX. 00000
Site Address: XXXX E Mason Lake Dr West
Primary Parcel Number: 221055100057
New grinder pump with Class A Waiver to reduce minimum
Permit Description: horizontal setback between septic transport line and non-public
wells from 50 ft to not less than 25 ft
Permit Submitted Date: 06/23/2025
Permit Issued Date: 07/14/2025
Issued By: David Anderson
Current Permit Fees Paid: $270.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 06/23/2026 (based on date of inspection)
Type of Work OSS New Construction
Components being Replaced: Other
Surfacing Sewage? No Existing Failure? No
Shoreline? No Horizontal Setbacks Met? No
Number of Bedrooms: 3 Drinking Water Source: Private Well/Spring
Additional Details: Orenco 250 gal 30 inch pump basin
Permit Conditions:
4 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.
1 Horizontal setbacks per WAC246-272A-0210 must be maintained, unless prior approval is
obtained
3 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/OR DESIGN
APPROVED.
FINAL INSTALLATION APPROVAL IS REQUIRED PRIOR TO TEMPORARY OR FINAL OCCUPANCY OF ANY RELATED STRUCTURES.
For Final Inspection visit: masoncountywa.govlhealth/environmental/onsiteloss-inspection-request.php or call:
360-427-9670, extension 400.
OFFICIAL USE ONLY
MASON COUNTY DATE RECEIVED ^n /�O^� N D
OW COMMUNITY SERVICES AMOUNT RECEIVE di rki RECEIVED BY
CO• m
Public Health(Community Health/Environmental Health) C
415N6thStr ext.400an,WA 54467.ext.a00 SWG 2oZ' - 0021 I O 0
415 N.6M Street•Shelton,WA 98584 �y./�/
Z 6
ON-SITE SEWAGE TANK ONLY APPLICATION
D D
E
APPLICANT PHONE .) m n r
BRAD ANDERSON 7 ri Z
MAILING ADDRESS-STREET.CITY.STATE.ZIP CODE N • E
2420 NE BOULDERSTONE CT - POULSBO, WA 98370 o m
SITE ADDRESS-STREET,CITY,ZIP CODE '
MA
XXXX MASON LAKE DRIVE WEST- GRAPEVIEW, WA 98546 `v I N
NAME OF DESIGNER ' PHONE N
ROBERT H. PAYSSE 360-426-1803
NAME OF INSTALLER PHONE r ' m
— v
TBD
TYPE OF WORK(select one) DRINKING WATER SOURCE
v O
11 NEW CONSTRUCTION/UPGRADES ❑ REPAIR/REPLACEMENT 0 PRIVATE INDIVIDUAL WELL ❑ PRIVATE TWO-PARTY WELL Z I Crl
COMPONENT(S)TO BE REPLACED/INSTALLED El PUBLIC WATER SYSTEM
❑ SEPTIC TANK 0 PUMP TANK 0 RV HOLDING TANK BEDROOMS LOT SIZE I Ul
® OTHER SOLIDS HANDLING 3 0.5
co
r
OTHER DETAILS(select all that apply) TANK(S)SETBACK CHECKLIST 0
❑ SURFACING SEWAGE 0 EXISTING FAILURE 0 SHORELINE 1 100FT+PUBLIC/COMMUNITY WELLS 0 1
• 0
SUBMITTALS 0 SOFT+PRIVATE WELLS,SURFACE WATERS,STREAMS,RIVERS
III PLOT PLAN(REQUIRED) ® TANK CROSS SECTION(REQUIRED) 0 10FT+DRINKING WATER SUPPLY LINES O
M PUMP DETAILS(IF APPLICABLE) II WAIVER(S)(IF APPLICABLE) El 5FT+PROPERTY/EASEMENT LINES,FOUNDATIONS,FOOTINGS
r
PLOT PLAN CHECKLIST Q CD❑! PROPERTY LINES AND EASEMENTS 0 EXISTING/PROPOSED STRUCTURES 8 EXISTING/PROPOSED OSS COMPONENTS AND LINES --
❑� WELLS WITHIN 100FT MI WATER SUPPLY LINES IE DRIVEWAYS/PARKING ❑ SURFACE WATERS.STREAMS,RIVERS,ETC... I CTl
I!7 DIRECTION OF SLOPE/CONTOURS 13 PERIMETER/CURTAIN DRAINS ® NORTH ARROW IIIII SCALE BAR
DIRECTIONS TO SITE AND SITE CONDITIONS'(ex locked gate) J
N HWY 3, LEFT ON MASON LK RD. CONTINUE TO MASON LAKE. LEFT ON MASON LAKE
DRIVE WEST (BACK SIDE OF LAKE). FOLLOW AROUND, LOT IS JUST PAST SITE
ADDRESS 3400 ON RIGHT (WATERSIDE). SEE SITE PLAN.
SEE ALSO, APPROVED SWG2024-00442
OFFICIAL USE ONLY BELOW THIS LINE
UPGRADE/FAILURE SOURCE(for reporting purposes)
O VOLUNTARY 0 MAINTENANCE/PUMPING 0 BUILDING PERMIT ❑HOME SALE El COMPLAINT ❑OTHER:
COMMENTS/CONDITIONS
Mc i r/ndcr f )
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 I APPLICATION EXPIRATION DATE APPLICATI PPROVEDI ISSUED BY DATE
6f z3/?d 7 6 WIY/TO7r
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE REVISED 12///2015
DESIGN FORM—PAGE ONE Assessor's Parcel Number: 2 2 1 0 5 — 5 1 — 0 0 0 5 7
A design will be reviewed when 3 copies of each of the following are submitted:
'1 Completed design form that has been signed and dated. '1 Scaled layout sketch,including all applicable items on checklist.
Scaled plot plan,including all applicable items on checklist. ''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 262 -cx 24 1 Designer's Name: ROBERT H. PAYSSE
BRAD ANDERSON Designer's Phone Number: 360-426-1803
Applicant's Name:
Mailing Address:
2420 NE BOULDERSTONE CT Designer's Address: 3083 E MASON BENSON RD
POULSBO WA 98370 City State Zip GRAPEVIEW WA 98546
City State Zip Designer's Email pioneerdigging@yahoo.com
DESIGN PARAMETERS
Treatment Device
❑Glendon 0 Sand Filter ❑Mound 0 Sand Lined Drainfield 0 Recirculating Filter 0 ATU ILI OthecTANK ONLY
Treatment Level(check all that apply): D A ❑ B ❑C ❑ BLI ❑ BL2 :BL3 ❑ E ❑N
Drainfield Type
❑Gravity 0 Pressure 0 Trench 0 Bed 0 Sub Surface Drip
Septic Tank/Drainfield Specifications Laterals
Number of Bedrooms 3 Schedule/Class -
Daily Flow:Operating Capacity 270 gpd Length - ft
Daily Flow:Design Flow 360 gpd Diameter - in
Septic Tank Capacity(working) - gal Number -
Receiving Soil Type(1-6) - Separation - ft
Receiving Soil Appl.Rate - gpd/ft2 Orifices
Required Primary Area - ft2 Total Number of Orifices -
Designed Primary Area - ft2 Diameter - in
Designed Reserve Area - ft2 Spacing - in
Trench/Bed Width - ft Manifold
Trench/Bed Length - ft Schedule/Class -
Elevation Measurements Length - ft
Original Drainfield Area Slope - % Diameter - in
New Slope,If Altered - % Preferred manifold configuration used? ❑Yes 0 No
Depth of Excavation Up-slope - in Transport Pipe
from Original Grade Do -slope - in Schedule/Class SCH.40
Designed Vertical Separation - in Length 250 ft
Gravel-based Drainfield Required? 0 Yes 0 No Diameter 1.5 in
Pump Required? B1 Yes 0 No Dosing and Pump Chamber
Pump/Siphon Specifications Number of doses/day ON DEMAND
Diff. in Elevation Between Pump& Uppermost Orifice 85 ft Dose quantity - gal
Drainfield Squirt Height/Selected Residual(head) - ft Chamber Capacity(flood) 250+1- gal
Uppermost Orifice 0 Higher 0 Lower than Pump Shutoff Pump controls: Please check those required.
Capacity @ Total Pressure Head 15 gpm 0 Timer 0 Elapse Meter 0 Event Counter
Calculated Total Pressure Head 95 ft If Timer: Pump on - ,Pump off -
Comments
ON DEMAND GRINDER PUMP & LINE UP TO TIMED SYSTEM (SWG2024-00442).
Revised:4/14/2025
DESIGN FORM—PAGE TWO Assessor's Parcel Number:2 2 1 0 5 — 5 1 -- 0 0 0 5 7
Permit Number: SWG
DESIGN CHECKLISTS
Scaled Plot Plan Scaled Layout Sketch Cross-Section Sketch
Et Test hole locations 0 Drainfield orientation and layout Reference depth from original grade:
g Soil logs 0 Trench/bed dimensions and 0 Septic tank
g Property lines critical distances within layout 0 Drainfield cover
g Existing and proposed wells 0 D-Box/Valve box locations Reference depth from original grade
within 100 ft of property g Septic tank/pump chamber and restrictive strata:
• Measurements to cuts, banks,and locations 0 Laterals,trench/bed,top and
surface water and critical areas 0 Observation port location bottom
O Location and orientation of 0 Clean-out location 0 Curtain drain collector
curtain drain and all absorption 0 Manifold placement 0 Sand augmentation
components 0 Orifice placement Other cross-section detail:
g Location and dimension of 0 Lateral placement with distance 0 Observation ports/clean-outs
primary system and reserve area to edge of bed
g Other Information
it Buildings g Audible/visual alarm referenced Yes No
Direction of slope indicator g Scale of drawing shown on scale 0 111 Design staked out
g Waterlines bar 0 g Recorded Notices attached
g Roads,easements,driveways, ❑ Elevation benchmark and relative lif 0 Waiver(s)attached
parking elevations of system components if 0 Pump curve attached
1 North arrow and scale drawing 0 I1'Evaluation of failure
shown on scale bar Non-residential justification
❑ L Waste strength
o g Flow
DESIGN APPROVAL
The undersigned designer must be notified b installer at time of installation g Yes 0 No
Par b(74 ( ate Signature of esigner AA
The undersigned has reviewed this design on behalf of Mason County Public Health and determined ii/ti
compliance with state and local on-site regulations: 41gS°�,C ✓(/� , Ilk
�����ZO 7S O4 y<ozs4.1
En ironmental Health Specialist Date 0`��°,o
IS �
CAUTION: DESPov � ONLY UNDER THE FOLLOWING CONDITION: /�FqTy✓ The design is amped"Approved" by VALIDao
✓ The Onsite Sewage Permit has not expired,the Permit Expiration Date is: di Z3( ?O?6
V 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
•
5WG2024-00442
o PROPOSED DRAIN FIELD r 'i
- OP,O vs PRIMARY & RESERVES }�
5� 7 \ FUTURE I itZ0i -OOQ'(7 b "
p� DRIVEWAY
S '' _
ADDITIONAL PERMITTING
•` I �/ 1� ; .� REQUIRED FOR TRANSPORT
rI .. LINE INSTALLATION
, \\ WITHIN COUNTY ROAD.
/ \---__----- .\ \
/ _f' ` \ \
PROPOSED '� / EXISTING WELL �\
BIO-BARRIER ,' . > i / \ I INSTALLER TO TEST
I _I_ / \ @,50 I 1 TRANSPORT LINE FOR
MBR 0.5-N I --,,l \ 1 I I LEAKS AFTER
O
// /i'i •� I I\ �\ \�\\ / R75' I I INSTALLATION PER
I N-. \ �\ / WAIVER
1 RCS- \vim \ � ���_� \ �/ �'�/ REQUIREMENT.
I \ \ \ / �' /
1 I /\ ♦ \ \ 1 hi
I R25' ~I \\ O 'N \\1 I ,I/I, /
j I\ I\\ 2/,\ % —T� % I �// PROPOSED 1.5"TRANSPORT
\ \ .... • - / / L� '��- LINE.DBL SLEEVED INO HDpBORE
\ EXISTING WELL __�-
� E
\ \. 7-�-- - Q�J&
• BORE PIPE.
BORE PATH TO \� \_y _/ �.`��
MAINTAIN 25 + O� PROPOSED SOLIDS
FROM WELLS •
HANDLING TANK
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4
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MqS .44 0 ' ` vAir," `
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i 0..' ROBEDT'III'TPAYSSE 15 • PROPOSED HOME V ‘V
.fir ..I'-''' '. ,.1 (fj,.... ` O
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EXPIRES \\\
AN ASBUILTI INSTALL SIGNOFF FEE WILL
BE CHARGED AT TIME OF INSTALLATION \ - \
PIONEER DIGGING, INC.
CUSTOMER: BRADLEY ANDERSON TANK C'\LY,NO TFST I IC'L[S
PARCEL A:22105-51-00057
SEPTIC DESIGNS ADDRESS: XXXX MASON LK DR.W
3083 E MASON BENS)N RD. GRAPEVIEW,WA 98546 DESIGNER: ROBERT EL PAYSSE FmLAI"' TINS IS NOT A SURVEY.REFERENCES INCLUDE APPLICANr/COUNTY PROVIDED
PUTS OR SURVEYS.FIELD MEASUREMENTS AND COUNTY G15 DESIGN INTENDED FOR SEPT1C
OFFICE 360 4261803 FAX 360 427 2353 NT MAY BE SUBJECT TO OTHER
\ DEPARTMENT AGENCY REVIEW DEPURPOSES ONLY SIGIER NOT RFESPONSIBLE FOR SETBACKS UNRELATED TO
HEFT: SITE PLAN SCALE 1"=40' SEPTIC COMPONENTS
I '
ALL ELECTRICAL IS TO
BE DONE BYA
LICENSED ELECTRICIAN
HIGH WATER ALARM
0
BOLT ON, GASKET LID
FLOAT TREE
UN ION/CHECK/BALL VALVE
n
0 - ,
RUBBER
GROMMET
RUBBER 0
GROMMET
INSTALL PER
MANUFACTURERS
INSTRUCTIONS 7FT
APPR®vED •
)JUL 1 250 GALLON
ORENCO 30"
MASON COUNTY 4 2025 PUMP BASIN 7FT
ENVIRpNP,1ENlgLyEgLTN, IN HEIGHT
am
GRINDER ill
PUMP, SEE TYPE
—
I
INC. TOMER: BRADLEY ANDERSON SCALE:NA
PIONEER DIGGING, 1�l PARCEL# 22105-51-00057 -IISE BOLT ON LID WITH GASKET
SEP I IC, DESIGNS ADDRESS: XXX MASON LK DR W -INSTALL TANK ON ORIGINAL SOIL
-USE GOOD SANDY BACKFILL MATERIAL
3083 E MASON BEN N RD. GRAPEVIEW,WA 98546 DESIGNER: ROBERT H.PAYSSE -l1SE RUBBER GROMMETS ON RISER FOR A
OFFICE-360-426-1803 FAX-360-427-2353 DESIGN PAGE SOLIDS TANK WATER-TIGHT SEAL
LSG200-Series
io
Performance Curve Dimensional Data Pha
60 Hz, 3450 RPM ®it
Liters Per Minute iygS,O C JU/ �O
0 37.9 75.7 113.6 151.4 189.3 227.1 ``
120 36.6 r�� 1 00 202�!'
I��
110 33.5 ISM II Nl//ROH
100 30.5leN1 Oj 4i4-4/ H
90 ' 57 v.a4. /,_
80 24.4 v litc. pli,
.c 70 21.3 2I '
5 IT I I I 19-1/2'
v 60 18.3 A
I w r
15.2 =
m 50 I 1-1/4"NPT
' 40 12.2 ,2 Discharge
30 9.1 iliaiL
1`_ _
20 6.1 Automatic Model
3-3/8' l`� Turn-On 15"
10 3.0 `� �I III' Turn-Off 8"
0 0 (adjustable)
0 10 20 30 40 50 60 9-1/2'
US Gallons Per Minute
Models
LOCKED FLOAT WEIGHT
MODEL HP VOLTS PH HZ AMPS ROTOR AMPS DISCHARGE SWITCH IN LBS
LSG202A 2 208/230 1 60 15 53 1-1/4" Yes 86
LSG202A-5-Y 2 208/230 1 60 15 53 1-1/4' Yes 86
LSG202M 2 208/230 1 60 15 53 1-1/4' No 84
LSG202M-C 2 208/230 1 60 15 53 1-1/4" No 91
LSG203M 2 208/230 3 60 10.6 62 1-1/4' No 84
LSG204M 2 440-480 3 60 5.3 31 1-1/4" No 84
LSG205M 2 575 3 60 4.9 24 1-1/4" No 84
1-phase models are thermally protected.3-phase models require a properly sized control panel.Maximum intermittent fluid temperature 140°F.
*Models with'Y•suffix feature 50'integrated Y-cord with float switch and bare leads.
LSG202M and LSG202A Options for LSG202M-C: External Cap Grinder
feature internal capacitors
and do not require a separate MODEL DESCRIPTION
control panel for operation. K001316 Start/Run Capacitor Kit for retrofit in existing panels
LSG202M C features external SXHC24=3-3 Simplex NEMA 4X Panel with start/run capacitors
capacitors,requiring a panel
with appropriately sized start AE24HC=3-3 Duplex NEMA 4X Panel with start/run capacitors
and run capacitors. For complete panel specifications.see SX or AE-series literature.
25'cord standard on au models.LSG202M-C features 35'cord standard.Y-cord models have a 50'cord.
GR20 Guide Rail Base (GR20 option sold separately)
•Cast iron construction
rl •Single 1-1/4"guide rail pipe design
L1!L
1Auto alignment feature
1 •GR20 works only with LSG-Series pumps
I ... 1 •
I!Ii
: •Upper rail support bracket
speciecatonssur�ecttoct,ange without nouce. Liberty Pumps-7000 Apple Tree Avenue-Bergen,New York 14416
Copyright 0 Liberty Pumps.Inc.2024 All rights reserved.LLIT003200 R05/24E Phone •
800 543-2550-Fax 585-494-1839 LibertyPumps.com
Installation & System Notes
1. Installer must contact designer for final inspection of the installation prior to cover. All components, including tanks, lids,
transport line,drainfield, and water lines must be open for inspection. A$350.00 fee will be charged for time involved with the
inspection of the installation and creation of the record drawing. The designer reserves the right to charge additional fees if
multiple visits are needed due to installation errors or inaccessible components.
2.This septic design must be installed by a certified installer with the local health department. All components shall be installed
according to state,county, and manufacturer requirements. For Homeowner Installs,the owner must get approval from the
designer and local health department prior to attempting installation.
3. Designer is not a surveyor. Installer must familiarize themselves with property line locations prior to installation. Any
confusion or conflicts with line locations should be reported to the property owner. A licensed surveyor may be necessary prior
to installation to confirm all line locations. Any discrepancies found must be reported to the designer immediately.
4. Drainfield area may only be cleared by a licensed installer familiar with sensitive drainfield area preservation. The builder, lot
developer, or property owner shall not clear the drainfield area. Any clearing required for drainfield installation shall not
remove or disturb any top soil in Primary and Reserve areas. Removal or disturbance to drainfield soils could render design
void.
5. The property owner and installer are responsible for locating all underground utilities (ex.water,gas,electric) prior to
installation. Any utility locations shown within design drawings are likely approximate and may not be exact.
6. All proposed tanks must be installed on original soils or compacted gravels. Extend all tank connection lines out onto original
soil to avoid settling issues. Risers and lids must be brought to finished grade and left accessible for future operations and
maintenance. Component manufacturers (ex. ATU, Glendons,) may have other requirements not listed within this design.
7. All electrical wiring shall be done by a licensed electrician or homeowner(if allowed) and must be permitted through Labor
and Industries. Designer not responsible for electrical permitting or other electrical specific code requirements.
8.The proposed septic system should be installed in dry weather conditions. Any failed attempts at installation during wet
weather conditions may render this design void.
9. Maintain 10ft to waterlines with all septic components. If less than loft is required, sleeving in sch.40 pvc is required. If
sewage transport lines and waterlines must cross,waterline must be 18" above sewage line with one of the lines sleeved in sch.
40 pvc 10ft in each direction of crossing.
10. This design may include waiver applications with specific mitigation measures pertaining to installation,operation and
maintenance of the proposed components.
11. Stormwater runoff,footing drains, roof drains must be diverted away from any septic system components. No curtain,
foundation, perimeter drains shall be installed 30ft downslope and loft upslope of drainfield areas.
12.This design is site specific and intended to meet state and county requirements that are related to the system components
being proposed. Any placement of proposed buildings, proposed wells or other non-related items on these drawings may or
may not meet other requirements.
13. All onsite septic systems require regular maintenance to verify satisfactory operation. The system owner/operator is
responsible for the continuous operation and maintenance of the system per WAC 246-272A. For o eration and maintenance
information, refer to Mason County Public Health Homeowner's Manual, which should be receive fpip I
14. System owner should be cautious of landscaping around septic components. Root intrusion
can cause premature failure of the drainfield area. In addition, bushes and trees should be kept JUL 14 2025
away from lids and other septic maintenance points. h1ASON COU
15. Changes made at time of installation may impact designer calculations, pump sizing, and ENVIRONMENTAL HEAL?;
compliance w/county and state requirements. Contact designer prior to install w/any g'•:� JA
proposed variations from design. Changes may result in additional fees and permitting. r'op,,,sh.'
PIONEER DIGGING, INC. CUSTOMER: BRADLEY ANDERSON
PARCEL#:22105-51-00057 slow
Y 0:: ROBERT H WIYSSE
SEPTIC DESIGNS ADDRESS: XXX(MASON LK DR W • -. 'F
il)83 E MASON BENSON RD. GRAPEVIEW,WA 98546 DESIGNER: ROBERT H.PAYSSE EXF'R`'
OFFICE-360426-I803 FAX-360-427-2353 SI WET: NOTES SCALE NA