HomeMy WebLinkAboutSWG2025-00183 - SWG Application / Design - 5/19/2025 (2) MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON:360427-9670,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 Permit: SWG2025-00183
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 ELSTROTT* Phone: 360-561-5000
Address: 128 NORTH RIVER STREET MONTESANO, WA 98563
Site Address: 4464 W STATE ROUTE 108
Primary Parcel Number: 419273200010
Permit Description: Repair/upgrade 5bd pressure trench to combine proposed ADU with
existing main home- REVISION
Permit Submitted Date: 05/19/2025
Permit Issued Date: 06/02/2025
Issued By: Rhonda Thompson
Current Permit Fees Paid: $990.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 08/29/2026 (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/environmentallonsiteloss-inspection-request.php or call:
360-427-9670, extension 400.
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OFFICIAL USE ONLY
MASON COUNTY DATE RECEIVED; U1((1 h�
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A!%,OUNT RECEIVED: 1 6 RECEIVED BY �� co ()
- Public Health & Human Services 1Y 0/1((l,.t a m cn
Environmental Health 360-427-9670,ext.400 or 360-275-4467,ext.400 �� O i\I(a� (n o
415 N.6th Street Shelton,WA 98584 - UVI
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ON-SITE SEWAGE SYSTEM APPLICATION
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APPLICANT PHONE r
//9i/sr c% C�`lS7Lr y c_,7iu✓I 360 — 7G'o —3e 9 D C
MAILING ADDRESS-STREET,CITY,STATE,ZIP CODE W
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SITE ADDRESS-STREET,CITY.ZIP CODE
yysel w se. /09 ; 5- e_.)2119.'N ; w/Q 98.rC9/ 41 I1C
NAME OF DESIGNER PHONE
CJi/"is L/s74r-a /` 26,„ - s--6/— s---000
NAME OF INSTALLER PHONE a I\(�VJ
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PERMIT TYPE(select one) DRINKING WATER SOURCE O
Et-Rtgli)ENTIAL OSS h COMMUNITY OSS F1 COMMERCIAL OSS Fki RIVATE INDIVIDUAL WELL n-PRIVATE TWO-PARTY WELL Z I�
TYPE OF WORK(select one) a.PUBLIC WATER SYSTEM I
Ij NEW CONSTRUCTION I UPGRADES b-REPAIR/REPLACEMENT OTHER DETAILS(select MI that apply) ❑ TABLE X REPAIR I
SUBMITTALS 0 SURFACING SEWAGE 0 EXISTING FAILURE ❑SHORELINE co
DESIGN FORM(REQUIRED) EPTIC DESIGN(REQUIRED) BEDROOM LOT SIZE WAS LOT CREATED,AFTER4/1/2025?
r IN
n]WAIVER(S)(IF APPLICABLE) y 97 44, El YES Ly^Tvu 0 I
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DIRECTIONS TO SITE AND SITE CONDITIONS:(ex locked gate)
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6/4t/ a/X J/ /08 /S f />7i' G✓is 2L" AN_- , //S A-14v /o/- (gip Gcr—/c G .�1 F
SITE MUST BE FLAGGED FROM MAIN ROAD AND TEST HOLES MUST BE FLAGGED WITH TEST HOLE NUMBERS. I
OFFICIAL USE ONLY BELOW THIS LINE
UPGRADE/FAILURE SOURCE(for reporting purposes)
0 VOLUNTARY 0 MAINTENANCE/PUMPING 0 BUILDING PERMIT 0 HOME SALE ['COMPLAINT 0 OTHER:
INSPECTOR SOIL LOGS COMMENTS/CONDITIONS
J r-0(6( bo( 4-0
0,4
cmwot4A- f`1 n ki ►L .
- 0 --72. L33 •
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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 BY DATE
R0 f--/ S 1 f317-:
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: y / 9 2- 7 3 z a" e d / CI
A design will be reviewed when 3 copies of each of the following are submitted:
0 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. °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 021.-- DD/e3 Designer's Name: C.U,t'/S ELSTR.c27
Applicant's Name: fin i 6./G' Cc.,57'� Designer's Phone Number: 310 �vo0
Mailing Address: //O Gf/, � ST ..5,i-G
Designer's Address: /Ze 4.' r e/G.4/2 S7
SW G h Gv/I Ors2 y City State Zip /- �✓24� 109 9d rb.j
CityState {� Zip Designer's Email P�.5 ' G' 4o/ Qo.,,
�x,: '�,. `� �'�� ���` ESIG1Y�R,i�RETERfi«#.�r�.:�,�:' WN.. :�S �,� ,�.�.a,. �nn
Treatment Device
❑Glendon 0 Sand Filter 0 Mound 0 Sand Lined Drainfield 0 Recirculating Filter 0 ATU 0 tither ?i_= •�s
Treatment Level(check all that apply): ❑A ❑B ❑C ❑BLI ❑BL2 ❑BL3 ❑E ❑N ery,ec.,ern44,6 6-13'
Drainfield Type
❑Gravity ressure rench 0 Bed 0 Sub Surface Drip
Septic Tank/Drainfield Specifications Laterals
Number of Bedrooms Schedule/Class 44
Daily Flow:Operating Capacity 'iS-0 icQr, gpd Length 6� ft
Daily Flow:Design Flow 6Gqo gpd Diameter /7/ in
Septic Tank Capacity(working) 2 /zop gal Number 6
Receiving Soil Type(1-6) 4/ Separation )j q 0 ft
Receiving Soil Appl.Rate Q. G gpd/ft2 Orifices
Required Primary Area /QGp ft2 Total Number of Orifices , 72.
Designed Primary Area /Dffp ft2 Diameter //4 in
Designed Reserve Area /79D ft2 Spacing 60 in
Trenc ed Width 3 ft Manifold
Trench/Bed Length 36-a ft Sche le/Class /0.
1
Elevation Measurements Length 4/.- ft
Original Drainfield Area Slope to % Diameter 2 in
New Slope,If Altered cg % Preferred manifold configuration used? 0 No
Depth of Excavation Up-slope so in Transport Pipe
from Original Grade Down
_slope Z7 in Scl_isslale1Class VP
Designed Vertical Separation 36 A in Length ,7.3-1, ft
Gravel-based Drainfield Required? 0 YesYe� 121- Diameter -1 in
Pump Required? I8'Yes 0 No Dosing and Pump Chamber
Pump/Siphon Specifications Number of doses/day 6 y /a /�3/er Ai
Diff.in Elevation Between Pump&Uppermost Orifice V6 ft Dose quantity /640 gal
Drainfield Squirt Height/Selected Residual(head) 4,‘ ft Chamber Capacity(flood) /,l-p gal
Uppermost Orifice Q'Higher CILower than Pump Shutoff Pump contr :Please check those required.
Capacity @ Total Pressure Head 37 gpm Lehmer apse Meter vent Counter
Calculated Total op FIR 0 V E{i ft If Timer: Pump on de=. Pump off
Comments Ili- a,is&rTjke..onpi/
SEP 30 2025
MASON COUNTY ENVIRONMENTAL HEALTH
RET Revised:6/11/2025
DESIGN FORM-PAGE TWO Assessor's Parcel Number:9 / q Z. 7 3 Z D 010 / e>
Permit Number: SWG 702-5-- Gb/c3
DESIGN CHECKLISTS
Scale Plot Plan Scaled ayout Sketch Cross-Section Sketch
� Test hole locations 1infield orientation and layout Referencece depth from original grade:
L-Soil logs B Trenc ed dimensions and i�- �S is tank
6 ro erty lines ,.,critical distances within layout �Dramfield cover
D xisting and proposed wells �' D-BoxNalve b ocations Reference depth from original grade
ahm 100 ft of property tic tank/pump chamber and restrict' strata:
easurements to cuts,banks,and to c lions terals,trench/bed,top and
' surface water and critical areas D'ojservation port location bo om
ll/Location and orientation of CSC an-out location 0 Cu 'n Bra' ollector
curtain drain and all absorptionanifold placement 0 Sa Lion
components 7.09rifice placement Other cross a�ction detail:
EVLocation and dimension of C9'Lateral placement with distance —observation ports/clean-outs
primary system and reserve area0. t edge of bed
L14
uildings Other Information
�/�Bible/visual alarm referenced Yes No
Q�irection of slope indicator l Scale of drawing shown on scale 0 Gl ifesign staked out
Q aterlines bar 0 D1 orded Notices attached
0-4oads,easements,driveways, levation benchmark and relative 0 aiver(s)attached
plang elevations of system components �❑ Pip curve attached
North arrow and scale drawing 0 G-15valuation of failure
shown on scale bar No -residential ' tification
❑ strength
to
DESIGN APPROVAL
The undersigned designer must be notifi y installer at time of installation No
9-1a- zr
Signature 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:
WV\ 9, ND l'U(
Environmental Health Sp ialist Date
CAUTION: DESIGN APPROVAL IS VALID ONLY UNDER THE FOLLOWING CONDITION:
✓ The design is stamped"Approved"by Mason County Public Health. �, Q
✓ The Onsite Sewage Permit has not expired,the Permit Expiration Date is: .5 0I vU
✓ 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:6/11/2025
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