HomeMy WebLinkAboutSWG2026-00013 - SWG Application / Design - 1/12/2026 MASON COUNTY 415 N 6TH STREET,SHELTON, ,E 98584
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SHELTON:360-427-9670,EXT 400
a y BELFAIR:360-275-4467,EXT 400
u Y Public Health & Human Services ELMA:360-482-5269,EXT 400
FAX:360-427-7787
On-Site Sewage System Permit: SWG2026-00013 .OV
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APPLICANT DOWER PATRICK S&CAMI A Phone: 1.760.224.5738
Address: 1100 CALIFORNIA AVE SE PORT ORCHARD, WA 98366
OWNER DOWER PATRICK S &CAMI A Phone: 1.760.224.5738
Address: 1100 CALIFORNIA AVE SE PORT ORCHARD, WA 98366
SEPTIC DESIGNER DALE TAHJA* Phone: 360-463-8023
Address: 2450 W DEEGAN ROAD WEST SHELTON, WA 98584
SEPTIC INSTALLER TJ GOOS* Phone: 360-490-0217
Address: 150 E MARISA PL SHELTON, WA 98584
Site Address: 510 E Burgundy Rd
Primary Parcel Number: 220257900120
Permit Description: New 4bd gravity trench with Class B waiver
Permit Submitted Date: 01/12/2026
Permit Issued Date: 02/18/2026
Issued By: Rhonda Thompson
Current Permit Fees Paid: $845.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 01/13/2029 (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/onsite/oss-inspection-request.php or call:
360-427-9670, extension 400.
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OFFICIAL USE ONLY
MASON COUNTY' DATE RECEIVED: OI ' I ^ 1 Rc N
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Environmental Health 360-427-9670,ext.400 or 360-275-4467.ext'400 - O
415 N.6th Street-Shelton,WA 98584 SWG , h'� (,� - O I,(�,' g 2
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ON-SITE SEWAGE SYSTEM APPLICATION 1.
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APPLICANT PHONE m mo
Cami & Patrick Dower (760)224-5738 c
MAIL1NG DDRESS-STREET,CITY,CaliforniaAve.STATE, CODE
SE
1100 �`\� e Port Orchard WA 98366 m
SITE ADDRESS-STREET,CITY,ZIP CODE '��'
510 E. Burgundy Rd.
< /4Sheiton
WA 98584 I
NAME OF DESIGNER V PHONEDale L. Tahja (360)463-8023
NAME OF INSTALLER D PHONE Q I
T.J. Goos ': (360)490-0217
PERMIT TYPE(select one) DRINKING I IV
NKING WATER SOURCE
RESIDENTIAL OSS E;COMMUNITY OSS rB'CO � OSS IRJ PRIVATE INDIVIDUAL WELL El PRIVATE TWO-PARTY WELL Z I V1
TYPE OF WORK(select one) 03 PUBLIC WATER SYSTEM -rte! t
NEW CONSTRUCTION/UPGRADES REPAIR/REPLACEMENT OTHER DETAILS(select all that apply) ❑ I 'V
TABLE X REPAIR
SUBMITTALS ❑SURFACING SEWAGE O EXISTING FAILURE 0 SHORELINE W
CI DESIGN FORM(REQUIRED) El SEPTIC DESIGN(REQUIRED) BEDROOMS LOT SIZE WAS LOT CREATED AFTER 4/1/2025? G I
El WAIVER(S)(IF APPLICABLE) 4 7.36acre EYES NO
X IO
DIRECTIONS TO SITE AND SITE CONDITIONS:lex.locked gate) •
Go onto Harstene Island, right on South Island Dr., right on Harstene Island Rd., right on I o
Burgundy Rd., property directly west on Merlot Lande. o I IN
SITE MUST BE FLAGGED FROM MAIN ROAD AND TEST HOLES MUST BE FLAGGED WITH TEST HOLE NUMBERS. I O e;
OFFICIAL USE ONLY BELOW THIS LINE .
UPGRADE/FAILURE SOURCE(for reporting purposes)
0 VOLUNTARY 0 MAINTENANCE/PUMPING ❑BUILDING PERMIT ❑HOME SALE ❑COMPLAINT ❑OTHER:
INSPECTOR SOIL LOGS COMMENTS/CONDITIONS
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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
1 fr?J2 �l►�� �'
•THIS FORM MAY B�NED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE Revised:6/3/2025
■
DESIGN FORM—PAGE ONE Assessor's;Parcel Number: 2 2 0 2 5 7 . 9 0 0 1 12 0
3 + �
A design will be reviewed when 3 conies 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
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Permit Number: SWG 2(72J1/40 - 000(3 Designer's Name: Dale L.Tahja
Cami&Patrick Dower Designer's Phone Number: (360)463-8023
Applicant's Name:
Mailing Address:
1100 California Ave. SE Designer's Address: 2450 W.Deegan Rd.W.
Port Orchard WA 98366 City State Zip Shelton WA 98584
City State Zip Designer's Email
yrt `w''' i t*' e s t r -2MA Esn ',4,1M,y'+ h a : ft.
Treatment Device
O Glendon O Sand Filter O Mound O Sand Lined Drainfield O Recirculating Filter O ATU O Other
Treatment Level(check all that apply): :ROB O C O BL1 ❑BL2 ❑BL3 prE O N
Drainfield Type
Gravity O Pressure IdTrench O Bed O Sub Surface Drip
Septic Tank/Drainfield Specifications Laterals
Number of Bedrooms 4 Schedule/Class 2729
Daily Flow:Operating Capacity 360 gpd Length 67 ft
Daily Flow:Design Flow 480 gpd Diameter 4 in
Septic Tank Capacity(working) 1,200 gal Number 4
Receiving Soil Type(1-6) 4 Separation 6-13 ft
Receiving Soil Appl.Rate 0.6 gpd/ft2 Orifices
Required Primary Area 800 ft2 Total Number of Orifices 1,072
Designed Primary Area 800 ft2 ;Diameter 0.5 in
Designed Reserve Area 800 ft2 Spacing 5 in
Trench/Bed Width 3 ft Manifold
Trench/Bed Length 268 ft Schedule/Class 3034
Elevation Measurements Length 135 ft
Original Drainfield Area Slope 13 % Diameter 4 in
New Slope,If Altered 10 % Preferred manifold configuration used? O Yes l 'No
Depth of Excavation Up-slope 1` in Transport Pipe
from Original Grade Down-slope in Schedule/Class 3034
Designed Vertical Separation \V in Length 80 ft
Gravel-based Drainfield Required? O Yes Ei No Diameter 4 in
Pump Required? O Yes liNo Dosing and Pump Chamber
Pump/Siphon Specifications Number of doses/day Gravity
Diff.in Elevation Between Pump&Uppermost Orifice N/A ft Dose quantity Gravity gal
Drainfield Squirt Height/Selected Residual(head) N/A ft Chamber Capacity(flood) N/A gal
p controls:Please check those required.
Uppermost Orifice O Higher El Lower than Pump Shutoff
Capacity @ Total Pressure Head Gravity gpm O Timer O Elapse Meter O Event Counter
Calculated Total Pressure Head N/A ft If Timer: Pump Xf ,Pump off
Comments APPRU V
FEB 18 2026
MASON COUNTs{EHvIRUNMENTAL HEATH
RET Revised:6/11/2025
DESIGN FORM—PAGE TWO Assessor's Parcel Numbers 2 2 0 2 5 7 9 0 1 0 11J 2 101
Permit Number: SWG 20a(p - 00013
Scaled Plot Plan Scaled Layout Sketch Cross-Section Sketch
P1 Test hole locations le Drainfield orientation and layout Reference depth from original grade:
E Soil logs Er Trench/bed dimensions and Er Septic tank
l' Property lines critical distances within layout Er Drainfield cover
fie Existing and proposed wells Er D-Box/Valve box locations Reference depth from original grade
within 100 ft of property Er Septic tank/pump chamber and restrictive strata:
iir Measurements to cuts,banks,and locations liir Laterals,trench/bed,top and
surface water and critical areas lit Observation port location bottom
0' Location and orientation of le Clean-out location O Curtain drain collector
curtain drain and all absorption Er Manifold placement ( O Sand augmentation
components
er Orifice placement Other cross-section detail:
Er Location and dimension of Observation ports/clean-outs
primary system and reserve area Lateral placement with distance
to edge of bedle Other Information
Buildings O Audible/visual alarm referenced Yes No
er Direction of slope indicator
iii° �( O Design staked out
Scale of drawing shown on scale
Er Waterlines bar O O Recorded Notices attached
Er Roads,easements,driveways, il Elevation benchmark and relative d O Waiver(s)attached
parking elevations of system components O O Pump curve attached
Er North arrow and scale drawing O O Evaluation of failure
shown on scale bar Non-residential justification
❑ O Waste strength
❑ ❑Flow
k 1 ESIGN PP1ROVAL
The undersigned designer st be notifie italler at time of installation EYes O No
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Signature of Designer Date '
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The undersigned has reviewed this design on behalf of Mason County Public Health and det s mz
compliance with state and local on-site regulations: k3 rte° °N o w , l
, o b Environme�'. ealth Sp: ialist _ Date '���3'�s(e i
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CAUTION: DESIGN APPROVAL IS VALID ONLY UNDER THE FOLLOWING COND Mio -1
✓ The design is stamped"Approved"by Mason County Public Health.
✓ The Onsite Sewage Permit has not expired,the Permit Expiration Date is: q r5/ :,
✓ 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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APPROVED
FEB 18 2026
MASON COUNTY ENVIRONMENTAL HEALTH
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Installation/Maintenance
Gravity Distribution/Trench Systems
1. Install trench bottom level and in contour with the ground.
2. Install drainfield during dry weather and soil conditions.Any soil smearing must be
eliminated by hand raking any areas that get smeared.
3. Divert all storm water run-off away from septic system components.
4. No curtain(french) drains allowed within 10ft. of the up-slope edge of the drainfield and
reserve area.
5. No curtain (french) drains allowed within 30ft. of the down-slope edge of the drainfield
and reserve area.
6. Have the septic tank pumped or inspected every 3 to 5 years.
7. All material and workmanship must meet County and State requirements.
8. Install risers on septic tank.
9. Deviation from this approved design without prior approval from the Designer and
Mason County Health Department will make this design null and void.
10.The prepared Site Plan is not a survey, it is the owner's responsibility to verify property
line locations prior to installation. Any discrepancies must be reported to the Designer
immediately.
11.Locate all utilities prior to starting installation.
12.A Final Inspection and Record Drawing fee will be charged upon completion of the
septic system installation.
13.The installer will notify the designer, Dale Tahja(360) 463-8023, at least 48 hours prior
to the start of the septic system installation.
14.An additional re-design fee may be charged if changes are requested from the applicant
after the original design is approved.
Bk APPROVED��
:or . FEB 1 $ 2026
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