HomeMy WebLinkAboutSWG2025-00416 - SWG Application / Design - 10/17/2025 a , 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,EXT400
FAX:360-427-7787
On-Site Sewage System Tank Only Permit: SWG2025-00416 ( 00
APPLICANT WARDEN LANELL D Phone: 360-239-7779
Address: 490 E ISLAND LAKE DR SHELTON, WA 98584
OWNER WARDEN LANELL D Phone: 360-239-7779
Address: 490 E ISLAND LAKE DR SHELTON, WA 98584
SEPTIC DESIGNER DALE TAHJA* Phone: 360-463-8023
Address: 2450 W DEEGAN ROAD WEST SHELTON, WA 98584
SEPTIC INSTALLER JAMES MEDCALF* Phone: 360-426-9277
Address: PO BOX 1552 SHELTON, WA 98584
Site Address: 490 E ISLAND LAKE DR
Primary Parcel Number: 320065003036
Permit Description: Replace septic and pump tank
Permit Submitted Date: 10/16/2025
Permit Issued Date: 10/17/2025
Issued By: Rhonda Thompson
Current Permit Fees Paid: $270.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 10/17/2026 (based on date of inspection)
Type of Work OSS Repair
Components being Replaced: Septic and Pump Tanks
Surfacing Sewage? No Existing Failure? No
Shoreline? Yes Horizontal Setbacks Met? Yes
Number of Bedrooms: 2 Drinking Water Source: Private Well/Spring
Additional Details: Septic and pump tanks
Permit Conditions:
1 Approval of this septic permit does not approve the building location. Building location is
subject to approval from all applicable departments and regulations.
3 Permit must be installed by a Mason County Certified Installer unless prior written
authorization from Mason County is obtained.
5 Proposed development subject to zoning requirements and approval by the planning
department staff per Mason County Title 17.
2 Horizontal setbacks per WAC246-272A-0210 must be maintained, unless prior approval is
obtained
4 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.gov/health/environmental/onsite/oss-inspection-request.php or call:
360-427-9670, extension 400.
OFFICIAL USE ONLY
MASON COUNTY (b /�P I �5
COMMUNITY SERVICES AMOUNT RECEIVED: �O RECEIVED BY:
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360 4 2 7-907 0,.rt 4000,360-27S 04467.ext.400 `/A,/(/'�'
415 N. hSh DATE RECEIVED:ort-Sir9on.WA 98584 2Dg5 00 LI I O x
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ON-SITE SEWAGE TANK ONLY APPLICATION 3
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APPLICANT PHONE rrl
Wendy Armstrong / -'•N "- (360) 239-7779 z
MAILING ADDRESS-STREET,CITY,STATE,ZIP CODE i L j ' 3
490 E. Island Lake Dr., Shelton WA 98584, N m
SITE ADDRESS-STREET,CITY.ZIP CODE N : ``"'
490 E. Island Lake Dr., Shelton WA 985:' ED Lc) ICJ
NAME OF DESIGNER I--- PHONE I IV
Dale L. Tahja '=LJ O J (360)463-8023
NAME OF INSTALLER c ' -- 1 I PHONE v I Q
Active Underground LLC CO (360)239-7779 <
TYPE OF WORK(select one) DR KING WATER SOURCE O I O
O NEW CONSTRUCTION I UPGRADES II REPAIR/REPLACEMENT III PRIVATE INDIVIDUAL WELL 0 PRIVATE TWO-PARTY WELL Z I 0)COMPONENT(S)TO BE REPLACED/INSTALLED 0 PUBLIC WATER SYSTEM ` 1
® SEPTIC TANK ® PUMP TANK 0 RV HOLDING TANK BEDROOMS LOT SIZE I (,jr
❑ OTHER 2 0.68 acre Co
OTHER DETAILS(select all that apply) TANK(S)SETBACK CHECKLIST O I O❑ SURFACING SEWAGE ❑EXISTING FAILURE III SHORELINE ® 100FT+PUBLIC/COMMUNITY WELLS C) 1
SUBMITTALS
SOFT+PRIVATE WELLS,SURFACE WATERS,STREAMS,RIVERS • I CD
® PLOT PLAN(REQUIRED) III TANK CROSS SECTION(REQUIRED) II 10FT+DRINKING WATER SUPPLY LINESI CO
®PUMP DETAILS(1F APPLICABLE) ❑ WAIVER(S)(1F APPLICABLE) IIIEFT+PROPERTY(EASEMENT LINES,FOUNDATIONS,FOOTINGS
PLOT PLAN CHECKLIST O I G
i ® PROPERTY LINES AND EASEMENTS ® EXISTING!PROPOSED STRUCTURES MI EXISTING/PROPOSED OSS COMPONENTS AND LINES '
II WELLS WITHIN 100FT I®WATER SUPPLY LINES ® DRIVEWAYS/PARKING ®SURFACE WATERS,STREAMS,RIVERS,ETC... I W
® DIRECTION OF SLOPE/CONTOURS 0 PERIMETER/CURTAIN DRAINS I NORTH ARROW ® SCALE BAR I
DIRECTIONS TO SITE AND SITE CONDITIONS:(ex.locked gate)
Go out Union Truck Trail, left onto Island Lake Dr., keep straight at Y, property on the right.
OFFICIAL USE ONLY BELOW THIS LINE --
UPGRADE/FAILURE SOURCE(tor reporting purposes)
❑VOLUNTARY ❑MAINTENANCE/PUMPING ❑BUILDING PERMIT ❑HOME SALE ❑COMPLAINT 0 OTHER:
COMMENTS/CONDITIONS
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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 APPLICATION EXPIRATION DATE APPLICATION APPROVED/ISSUED BY DATE
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THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE REVISED 12/7/2015
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'APPROVED
OCT 17 2025
i MASON COUNTY ENVIRONMENTAL HEALTH
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APPROVED
OCT 17 2025
MASON COUNTY ENVIRONMENTAL HEALTH
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