HomeMy WebLinkAboutSWG2025-00424 - SWG - 11/4/2025 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
L 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 Permit: SWG2025-00424
APPLICANT CEZARY NOWOWIEJSKI Phone: 509-868-5691
Address: 2746 NW RUDE ROAD POULSBO, WA 98370
OWNER MORGAN DOROTHY I &WILLIAM R Phone:
EAddress: 2151 W CLOQUALLUM RD SHELTON, WA 98584
SEPTIC DESIGNER Hunter, Adam Phone: 360 753-1226
Address: 2201 93rd Ave SW Olympia, WA 98512
Site Address: W Cloquallum Rd
Primary Parcel Number: 420361400060
Permit Description: NEW 3BR SFR - NuWater BNR
Permit Submitted Date: 10/21/2025
Permit Issued Date: 11/03/2025
Issued By: Jeff Wilmoth
Current Permit Fees Paid: $555.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 10/30/2028 (based on date of inspection)
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.
2 Proposed development subject to zoning requirements and approval by the planning
department staff per Mason County Title 17.
3 Permit must be installed by a Mason County Certified Installer unless prior written
authorization from Mason County is obtained.
4 Drainfield installation not to exceed designed upslope and downslope depth specified on
design form.
5 Installer is responsible for obtaining Mason County installation approval prior to backfill of
system components.
6 Installer is responsible for obtaining Septic Designer/Engineer installation approval prior to
backfill of system components.
7 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.
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OFFICIAL USE ONLY
At : MASON COUNTY DATE RECEIVED: Io/aa .zva5 C
AMOUNT RECEIVED: RECEIVED Bf:
-r Public Health & Human Services (f 656 cA LI N E Moe CO CA
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Environmental Health 360-427-9670,ext.400 or 360-275-4467,ext.400 —
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415 N.6th Street -Shelton,WA 98584 S W G was _ a a Q 4 cg �
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CLEAR FORM ON-SITE SEWAGE SYSTEM APPLICATION
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APPLICANT PHONE rn rn
CEZAR NOWOWJIESKI 5098685691 z
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MAILING ADDRESS-STREET.CITY,STATE,ZIP CODE g
2746 NW RUDE RD � POULSBO WA 98370 m
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SITE ADDRESS-STREET,CITY,ZIP CODE `y'�
XX W CLOQUALLUM RD , �,"" Act /SHELTON WA 98584 I N
NAME OF DESIGNER -. v / PHONE
ADAM HUNTER ,``�V !/ 3607531226 I cn
NAME OF INSTALLER Ov PHONE a
I -P
TBD TBD _ o
PERMIT TYPE(select one) DRINKING WATER SOURCE 10)
c
RESIDENTIAL OSS LJ COMMUNITY OSS E IN
COMMERCIAL OSS Lt PRIVATE INDIVIDUAL WELL 6-PRIVATE TWO-PARTY WELL Z
TYPE OF WORK(select one) a PUBLIC WATER SYSTEM
c
NEW CONSTRUCTION/UPGRADES Ll REPAIR/REPLACEMENT OTHER DETAILS(select all that appty) ❑ TABLE X REPAIR I
SUBMITTALS I� O 0 SURFACING SEWAGE 0 EXISTING FAILURE 0 SHORELINE co
DESIGN FORM(REQUIRED) INJ SEPTIC DESIGN(REQUIRED) BEDROOMS LOT SIZE WAS LOT CREATED AFTER 4/1/20257 r I
C
L� WAIVER(S)(IF APPLICABLE) I
2 0.45 ❑ YES 0 NO � I
DIRECTIONS TO SITE AND SITE CONDITIONS:(ex.locked gale)
W CLOQUALLUM RD SOUTH TO DRIVEWAY FOR 2151 ON THE LEFT. I
I— I
O
I
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 I FAILURE SOURCE(for reporting purposes)
❑VOLUNTARY ❑MAINTENANCE/PUMPING 0 BUILDING PERMIT ['HOME SALE ['COMPLAINT ['OTHER:
INSPECTOR SOIL LOGS COMMENTS/CONDITIONS
I (,. -n 1l
/ K
P.--, )--1...5 )75 Pi+
SOIL CODES: RECORD DRAWING AND INSTALLATION REPORT
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 AP I ATION APPROVED/ISSUED BY DATE
�` 0 -3o.y5 l D- 3D- ?-b ob c� Pt' 5
THIS FOR M Y BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE Revised:4/14/2025
V'
DESIGN FORM—PAGE ONE Assessor's Parcel Number: 420361400060 -- --
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. 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 & 5- o��t4 Designer's Name: ADAM HUNTER
Applicant's Name: CEZAR NOWOWJIESKI Designer's Phone Number: 3607531226
Mailing Address: 2746 NW RUDE RD Designer's Address: PO BOX 162
POULSBO WA 98370 City State Zip OLYMPIA WA 98507
City State Zip Designer's Email JHANDASSOCIATES@HOTMAIL.COM
DESIGN PARAMETERS
Treatment Device
❑Glendon 0 Sand Filter 0 Mound 0 Sand Lined Drainfield 0 Recirculating Filter l'ATU XO2 LJ Other
Treatment Level(check all that apply): J A 1 B —IC J BL I I BL2 I BL3 I E IN
Drainfield Type OSCAR X02
❑Gravity 0 Pressure 0 Trench 0 Bed 0 Sub Surface Drip
Septic Tank/Drainfield Specifications Laterals
Number of Bedrooms 2 Schedule/Class OSCAR XO2
Daily Flow: Operating Capacity 180 gpd Length OS50 ft
Daily Flow: Design Flow 240 gpd Diameter 60 in
Septic Tank Capacity(working) 1000 gal Number 4
Receiving Soil Type(1-6) 4 Separation 0.5 ft
Receiving Soil Appl. Rate 0.6 gpd/ft2 Orifices
Required Primary Area 400 ft2 Total Number of Orifices OSCAR XO2
Designed Primary Area 400 ft2 Diameter OSCAR XO2 in
Designed Reserve Area 400 ft2 Spacing OSCAR XO2 in
Trench/Bed Width 1OFT AND 15FT ft Manifold
Trench/Bed Length 10FT AND 20FT ft Schedule/Class 40
Elevation Measurements Length 30 ft
Original Drainfield Area Slope 1 % Diameter 1 in
New Slope,If Altered 1 % fill(tiVdt ,, ion used? I2'Yes 0 No
Depth of Excavation Up-slope OSCAR XO2 in -'I rf-nsport Pipe
from Original Grade Down-slope OSCAR XO2 in ScpANIRCiti.s2t25 40
Designed Vertical Separation 12 i L� ��+V1R0����yTALhEALIh 40 ft
MASON COUP
Gravel-based Drainfield Required? 0 Yes Er No Diamete416' 1 in
Pump Required? l 'Yes ❑No Dosing and Pump Chamber
Pump/Siphon Specifications Number of doses/day 411
Diff. in Elevation Between Pump&Uppermost Orifice 6.4 ft Dose quantity 0.58 gal
Drainfield Squirt Height/Selected Residual(head) OSCAR ft Chamber Capacity(flood) 1000 gal
Uppermost Orifice I 'Higher 0 Lower than Pump Shutoff Pump controls:Please check those required.
Capacity @ Total Pressure Head 12 gpm &if Timer El'Elapse Meter Ni6 Event Counter
Calculated Total Pressure Head 17.256 ft If Timer: Pump on 30SEC ,Pump off 3MIN
Comments
Revised: 4/14/2025
DESIGN FORM—PAGE TWO Assessor's Parcel Number:420361400060 -- --
Permit Number: SWG aO26—(soya /
DESIGN CHECKLISTS
Scaled Plot Plan Scaled Layout Sketch Cross-Section Sketch
EZi Test hole locations 12 Drainfield orientation and layout Reference depth from original grade:
g Soil logs Er Trench/bed dimensions and Septic tank
Ef Property lines critical distances within layout a Drainfield cover
a Existingand proposed wells ' D-BoxNalve box locations
Reference depth from original grade
within 100 ft of property E2f Septic tank/pump chamber and restrictive strata:
Measurements to cuts,banks,and locations Laterals,trench bed,top and
surface water and critical areas E Observation port location bottom
g Location and orientation of a Clean-out location E' Curtain drain collector
curtain drain and all absorption l Manifold placement 12. Sand augmentation
components El' Orifice placement Other cross-section detail:
12( Location and dimension of t21 Lateral placement with distance la Observation ports/clean-outs
primary system and reserve area to edge of bed
12fBuildings Other Information
6"[( Audible/visual alarm referenced Yes No
12( Direction of slope indicator [X Scale of drawingshown on scale 12( 0 Design staked out
12 Waterlines bar 0 0 Recorded Notices attached
g Roads, easements,driveways, 0 Elevation be e l ' ' 0 Waiver(s)attached
parking elev n tion nt.`� ;1 0 Pump curve attached
.,
12 North arrow and scale drawing � ' "
%,,. � 0 Evaluation of failure
shown on scale bar '
N� F„AL,n ;NMI-residential justification
ou�s�v E;��s 411h� 0 0 Waste strength
MAS4�1 .17-' 0 0 Flow
DESIGN APPROVAL
The undersigned designer must b: not' ied by i staller at time of installation 'Yes 0 No
10/2125
Silire o D esigner Date
The undersigned has reviewed this d; on behalf of Mason County Public Health and determined it to be in
compliance with state and local on-sit- regulations:
Environmental Health Specialist Date
CAUTION: DESIGN APPROVAL IS VALID ONLY UNDER THE FOLLOWING CONDITION:
✓ The design is stamped"Approved"by Mason County Public Health.
✓ 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
PAGE 1
MASON COUNTY HEALTH DEPARTMENT
ON-SITE SEWAGE DISPOSAL SYSTEM DESIGN
SITE#: PARCEL#:420361400060
DATE SUBMITTED:10/21/2025 LEGAL/LOT#:
SUBMITTED BY: ADAM HUNTER
APPLICANT: CEZAR NOWOWJIESKI
ADDRESS:
I.CALCULATIONS
NUMBER OF BEDROOMS= 2
RESIDENTIAL GPD FLOW= 240
IF NON-RESIDENTIAL-GPD FLOW
WILL BE AS FOLLOWS:
GPD=
APPLICATION RATE= 0.6 GPD/FT2
REDUCTION=LEAVE BLANK IF NO REDUCTION TAKEN
DRAINFIELD SIZING
ABSORPTION AREA= 400 FT2
TRENCH LENGTH OR BED CONFIG.= 10FTX1OFT AND 20FTX15FT
PER OSCAR
II.WATERPROOF SEPTIC TANK
COMPOSITION AND SIZE= 1000GAL-X02 TANK
NEW OR EXISTING= NEW
III.DRAINFIELD CROSS SECTION
�{:-.•AND DEPTH= 0'-6"
IV. `' •. TIONS USING PIPE CLASS 40
� ORIFICE NETAFIM DRIPLINE
114%14
% 14N N�P�
•
O Gy OLE NTH DIAMETER FRICTIONFLOW
M LOSS
p� ( ) G
FT)
05Q SUPPLY 70.00 1.00 12.000 5.4280
RETURN 70.00 1.00 12.000 5.4280
TOTAL= 10.8560
"TOTAL HEAD LOSS "
1)FRICTION LOSS THROUGH SYSTEM= 10.856
2)ELEVATION DIFFERENCE = 6.400
ifr
10/21/25
�•,. TOTAL= 17.256
-' ADAM J-HUNTER vi
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40■■1111Mrr
PACE 2
V.CHECK THE PUMP CAPACITY.
PUMP: A.Y.MCDONALD 30GPM-1/2HP PUMP(MODEL#22050E2AJ) (PER OSCAR)
EXCESS TDH 50.00 (PER OSCAR)
TOTAL HEAD LOSS IN SYSTEM 17.26
STANDARD PUMP CONFIGURATION IS SUFFICIENT? YES
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