HomeMy WebLinkAboutSWG2026-00097 - SWG Application / Design - 4/3/2026 MASON COUNTY 415 N 6TH STREET,S-427-9 7 ,E 98584
• SHELTON:360-427 9670,EXT 400
JBELFAIR:360-275-4467,EXT 400
Public Health & Human Services ELMA:360-482-5269,EXT 400
FAX:360-427-7787
On-Site Sewage System Permit: SWG2026-00097
APPLICANT JACKSON LULA M Phone:
Address: 190 E STAVIS RD SHELTON, WA 98584
OWNER JACKSON LULA M Phone:
Address: 190 E STAVIS RD SHELTON, WA 98584
SEPTIC DESIGNER CINDY WAITE* Phone: 360-701-0205
Address: 80 E PICKERING LANE SHELTON, WA 98584
SEPTIC INSTALLER THAD BAMFORD* Phone: 360-790-2364
Address: 301 WALLACE KNEELAND BLVD STE 224-332 SHELTON, WA 98584
Site Address: 190 E STAVIS RD
Primary Parcel Number: 220185300144
Permit Description: Repair 3bd gravity bed
Permit Submitted Date: 04/03/2026
Permit Issued Date: 04/21/2026
Issued By: Rhonda Thompson
Current Permit Fees Paid: $845.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 04/09/2027 (based on date of inspection)
Permit Conditions:
I 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 Drain field 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
AS®N COUNTY DATE RECEIVED: o'-If ,.` ^ I ^ N D
U �IJ O)( C Cl)
AMOUNTRECEIV RECEIVED BY;
Public Health & Human Services v
Environmental Health 360-427-9670,ext.400 or 360-275-4467,ext.400 //�� N O
415 N.6th Street-Shelton,WA 98584 SVG — x�9� O
((J���`" z N
ON-SITE SEWAGE SYSTEM APPLICATION
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APPLICANT PHONE r
LULA JACKSON O z
C
MAILING ADDRESS-STREET,CITY,STATE,ZIP CODE
190 E STAVIS RD SHELTON WA 98584 M
SITE ADDRESS-STREET,CITY,ZIP CODE
190E STAVIS RD SHELTON WA 98584
NAME OF DESIGNER PHONE I N
CINDY WAITE Q 360-701-0205
NAME OF INSTALLER PHONE" v I
BAMFORD SEPTIC REPAIR m 360-790-2364
PERMIT TYPE(select one) DRINKING WATER SOURCE I� O
MI RESIDENTIAL OSS 5ICOMMUNITY OSS IöICOMMERCIAL OSS PRIVATE INDIVIDUAL WELL IUJ PRIVATE TWO-PARTY WELL z 100
TYPE OF WORK(select one) ]PUBLIC WATER SYSTEM TIMBERLAKE WS
I1 NEW CONSTRUCTION/UPGRADES REPAIR/REPLACEMENT OTHER DETAILS(select all that apply) ❑ TABLE X REPAIR c.31
SUBMITTALS1i 0 SURFACING SEWAGE 0 EXISTING FAILURE 0 SHORELINE
DESIGN FORM(REQUIRED) ]SEPTIC DESIGN(REQUIRED) BEDROOMS I LOT SIZE I WAS LOT CREATED AFTER4/1/2025? Q I W
IJWAIVER(S)(IF APPLICABLE) 3 .23 AC ❑ YES ❑✓ NO 1 )
DIRECTIONS TO SITE AND SITE CONDITIONS:(ex.locked gate)
GO INTO TIMBERLAKES, TURN LEFT ONTO TIMBERLAKES DRIVE, TURN LEFT.ON I I o
TO STAVIS RD, PARCEL IS ON THE RIGHT SIDE o I.—
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/FAILURE SOURCE(for reporting purposes)
❑VOLUNTARY ❑MAINTENANCE/PUMPING ❑BUILDING PERMIT ❑HOME SALE DCOMPLAINT ❑OTHER:
INSPECTOR SOIL LOGS COMMENTS/CONDITIONS
ll -�I� 5 a 't
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 FINALAPPROVAL.
INSPECTOR SIGNATURE DATE APPLICATION EXPI TION DATE TION APPROVED!;ISSUED_IY ATE
� v1
Revised:4/14/2025
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE
1
DESIGN FORM-PAG ONE Assessor's Parcel Number: 2 2 0 1 8 5 3 0 0 1 4 4
A design will be reviewed when 3 copies of each of the following are submitted:
Completed design form that ias been signed and dated. V Scaled layout sketch,including all applicable items on checklist.
Scaled plot plan,including al applicable items on checklist. Cross-section sketch,including all applicable items on checklist.
This form maybe sc nned and available for public view on the Mason County Web site.Maximum paper size: 11"X 17"
• P'_'3CEL LDENTIFICAT ONi
Permit Number: SWGWOeTjç i Designer's Name: CINDY WAITE
Applicant's Name: LULA JACKSON Designer's Phone Number: 360-701-0205
Mailing Address: 190 EISTAVIS RD Designer's Address: 80 E PICKERING LANE
SHEL1jON WA 98584 City State Zip SHELTON WA 98584
City State Zip Designer's Email cindyewaite@msn.com
; ._ 3DESIGNa�PAjfiAMIETERS' _
Treatment Device
O Glendon ❑ Sand Filter Mound O Sand Lined Drainfield ❑ Recirculating Filter O ATU O Other
Treatment Level(check all that apply): ❑A ❑B ❑C ❑BL1 ❑ BL2 ❑BL3 1cl E ❑N
Drainfield Type
Gravity ❑ ressure O Trench I 'Bed O Sub Surface Drip
Septic Tank/Dra nfield Specifications Laterals
Number of Bedrooms 3 Schedule/Class ASTM 2729
Daily Flow: Operating Capacit 270 gpd Length ,`•' :` 45 ft
Daily Flow:Design Flow 3604
gpd Diameter ;:'� �'•` �. • 4 in
Septic Tank Capacity(working EXISTING 1200 gal Number4 �'°.y ��;�' 3
Receiving Soil Type(1-6) 3 SepalZ % 3 ft
Receiving Soil Appl.Rate .8 f 1 e
gpd/ft' AITE-: :; ices
ICENgi.: ➢IGNEIR
Required Primary Area 450 ftz T' iii r TM 2729 PERF
Designed Primary Area 450 EXPIRES.b51101 4
ft2 Diameter in
Designed Reserve Area 450 ft2 Spacing in
Trench/Bed Width 10 ft Manifold
Trench/Bed Length 45 ft Schedule/Class ASTM 3034
Elevation 1 easurements Length 10-15 ft
Original Drainfield Area Slope "1 % Diameter 4
in
New Slope,If Altered % Preferred manifold configuration used? ❑Yes I�(No
Depth of Excavation Up-slope 24 in Transport Pipe
from.Original Grade gown-sloe 24
in Schedule/Class AS t'm 3 D i y
Designed Vertical Separation 36 in Length I ft
Gravel-based Drainfield Requir d? VYes ❑No Diameter
Pump Required? ❑Yes Gl'No Dosing and Pump Chamber
Pump/Siphoi Specifications Number of doses/day
Diff. in Elevation Between Pump&Uppermost Orifice ft Dose quantity P P al
g
Drainfield Squirt Height/Select d Residual(head) $ Chamber Capacity(flood) „ n gal
Uppermost Orifice❑Higher ❑Lower than Pump Shutoff Pump controls: Please check tho required.L
Capacity @ Total Pressure Hea gpm ❑ Timerr � e'V1ROP�4 VetiY���unter
Calculated Total Pressure Head 12.56 ft If Timer: Pump on ,p �of
Comments
��� �,�- sep��� -f�Q�v>� �,�, r�� Q�,�rua.�.l• 6 . �-�{c. atia rU�.�
Revised: 6/11/2025
DESIGN,FORM,—p' GE TWO Assessor's Parcel Number: 2 2 i 0 i 1 8 1 5 3 ( 0 0 1 1 4 1 4
Permit Number: SWG 'O
�CP OC377
7 _
DESIGN CHECKLISTS i
Scaled Plot Plan Scaled Layout Sketch Cross-Section Sketch
Vf Test hole locations 21 Drainfield orientation and layout
Pr Soil to s Reference depth from original grade:
g i1 Trench/bed dimensions and ❑ Septic tank
21 Property lines critical distances within layout
Jkxisting and propo ed wells V Drainfield cover
D-Box/Valve box locations
within 100 ft of prdperty 2 Septic tank/pump chamber Reference depth from original grade
AD/Measurements to c ts,banks, and locations f .6 1^ *1 IV and restrictive strata:
` 10 Laterals,trench/bed,top and
lll�ysurface water and c itical areas 21 Observation port location
'Location and orientation of bottom
,I&wClean-out location ❑ Curtain drain collector
curtain drain and al absorption V' Manifold placement ❑ Sand augmentation
components
[Q Location and dime sion of �40rifice placement Other cross-section detail:
primary system and reserve area Lateral placement with distance 21Observation ports/clean-outs
{� Buildings
to edge of bed Other Information
'Audible/visual alarm referenced Yes No
21 Direction of slope i dicator
2 Waterlines 19 Scale of drawing shown on scale i O Design staked out
21 bar ❑ ❑ Recorded Notices attached
Roads,easements, riveways, 7 Elevation benchmark and relative ❑ ❑ Waiver(s)attached
parking elevations of system components ❑ O Pump curve attached
21 North arrow and scale drawing ❑ ❑ Evaluation of failure
shown on scale bar
Non-residential justification
❑ ❑ Waste strength
- _ ❑ ❑ Flow
DESIGN APPROVAL; - 'j
The undersigned design r must be notified by installer at time of installation 'Yes ❑ No
y Zo
Signs 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 an local on-site regulations:
�,[ J
Environmental Health Specialist Date
CAUTION: DESIGN APPROVAL IS VALID ONLY UNDER THE FOLLOWING CONDITION:
✓ The design is stampe "Approved"by Mason County Public Health. I �y
✓ The Onsite Sewage P rmit has not expired,the Permit Expiration Date is:_
✓ Drainfield site condit ons have not been altered to adversely affect conditions of design approval.
Please Note: TI he system must be installed by a certified installer,
unless prior aut Lorization is obtained from Mason County Public Health.
An Installation ee 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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cs 190 E Stavis Rd, Shelton, WA 98584, USA, Timber Lake-Harstine Island Township, Parcel Id: 220'185300144
BENCH MARK \ '.:
" -
Foundation ij 100.00 ,'
Septic tank 2 99.50 >'r
Outlet 3 98.50 1 1 1
Bottom of drainfiel 4 96.50 a•
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it i
;11dl_l A 1 Q
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41 !
Z o _
y ',
's ® Parcel Lin Buffer 5 ft ' ''
I Residence
2 Existing 1200 gallon.septic tank
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3 Primary drainfield
_ 4 Failed existing systH--
em
5 Reserve drainfield
6 LWaterline
GIS Legend } _ {r ,
Measure Length
WA Mason 10 ft. Contours
1 - - '' ° Scale_> 1 in 20 F ' "
J __ __
so / /
da��k 5 L2
1 m Ill
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APPROVED
APR 2 1 2026
MASON COUNTY ENVIRONMENTAL �ALTH
RET •
�� �QCNAIY Y.,
APPROVED
APR 21 2026
MASON COUNTY ENVIRONMENTAL HEALTH
RET
Acres R erTo tirade
• tntetwith $,
- - Speed Le+re[e orew.% r• Levelk g Pad I
Distribution Box(No Skate)
Installation Notes
Gravity System
190 E Stavis Rd 22018-53-00144
1. The preps ed site plan is not a survey. It's the owner's responsibility to verify property
lines, utilityy lines (water, sewer, power, phone and gas) prior to installation.
2. Install cle pout between residence and septic tank
3. Install rises on existing septic tank
4. Gravel based drainfield required
5. Install syst m during dry weather with acceptable soil conditions
6. Keep whee ed vehicles off the drainfield area before, during and after installation.
Tracked eq ipment only
7. All ground, surface water and roof drains must be diverted away from the septic tanks
and drainfieId. Ensure the final grade slopes away from these areas and water doesn't
collect on or around them. Use swales, berms, catch basin and tight lines, curtain drains,
etc. to divert all waters.
8. Curtain drains can be no closer than 10' upgradient and 30' down gradient of the
drainfield
9. Exposed restrictive layers, cuts, banks, etc. can be no closer than 50' downhill from the
drainfield.
10. Install access risers on the septic tank, D-box and observation ports.
11. Make sure septic tank risers are epoxied or caulked to cast in riser rings on tank.
12. Lids must form a water and gas tight seal with the access risers
13. Install effluent filter at the septic tank outlet.
14. This systerr must be installed by a Mason County Certified Installer.
15. Deviation from this design without prior approval from the designer and Mason County
Health Dep rtment will make this design null and void.
16. This design was sized per Washington Administrative CodeWAC246-272A-0230. The
operating capacity is based on 45 gallons per day per capita with two persons per
bedroom. The minimum design flow per bedroom per day is the operating capacity of
ninety gallons multiplied by 1.33. This results in a minimum design flow of one hundred
twenty gallons per day. This creates a surge factor of 33% but anticipated flow is ninety
gallons per bedroom per day.
17. Install laterals or bed with contour of the ground
18. Install trench bottoms level and always maintain a minimum of six inches into native soil
19. Filter fabri required over drain rock prior to backf ing. If the drain rock extends
above the riginal grade, run the filter fabric at le inches down the trench wall
PROVED
APR 21 2026
MASO COUNTY ENVIRONMENTAL HEALTH 4"
L' : JEK
RET
EXPIHES U5,1Ii
System Owner Responsibilities:
1. Operation and Maintenance is required by Washington State Department of Health and
Mason County Health Department.
2. The septi 9 tank should be pumped every three to five years or as needed.
3. System owners are responsible for having maintenance performed every three years as
per WAC2146-272A.
4. System owners are responsible for responding to septic issues in a timely manner.
5. System owner agrees to read and abide•by information regarding their system in the
User Man I al provided by Mason County Public Health.
6. Keep the f ow of sewage at or below the approved design operating capacity.
7. Keep was a strength at residential waste strength parameters.
8. Spread to ds of laundry through the week.
9. Do not used excessive bleach or detergents with added whiteners.
10. Do not sh wer, do laundry and dishwasher at the same time
11. Antibiotics�can kill or impair the biological process in the septic tank.
12. Leaky plu bang can hydraulic overload your on-site septic system.
APPROVED Al
APR 2 1 2026
of 1NASy 9,s
MASON COUNTY ENVIRONMENTAL
RED