HomeMy WebLinkAboutSWG2026-00203-TANK ONLY - SWG Application / Design - 7/2/2026 MASON COUNTY 415 N 6TH STREET,SHELTON,97 ,WA 98584
• 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 Tank Only Permit: SWG2026-00203
APPLICANT QUEEN LISA Phone: 360-490-1223
Address: 3230 E STATE ROUTE 106 UNION, WA 98592-9501
OWNER QUEEN LISA Phone: 360-490-1223
Address: 3230 E STATE ROUTE 106 UNION, WA 98592-9501
SEPTIC INSTALLER DARIN OGG* Phone: 360-790-3021
Address: PO BOX 1336 HOODSPORT, WA 98548
APPLICANT DAVID ELLIS Phone: 360-480-2554
Address: 123 XXX XX, XX. 00000
Site Address: 3230 E State Route 106
Primary Parcel Number: 321063400030
Permit Description: Replace the existing septic tank with a 1200-gal Hagerman Pre-Cast
tank
Permit Submitted Date: 06/29/2026
Permit Issued Date: 07/07/2026
Issued By: David Anderson
Current Permit Fees Paid: $275.00 (additional fees may be required upon installation of system).
Permit Expiration Date: 06/29/2029 (based on date of inspection)
Type of Work Other
Components being Replaced: Septic Tank Only
Surfacing Sewage? No Existing Failure? No
Shoreline? Yes Horizontal Setbacks Met? No
Number of Bedrooms: 0 --Ua K... Drinking Water Source: Private Two-Party Well
Additional Details: Hagerman Pre-Cast 1200-gal
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.
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.
MASON COUNTY 415N6THSTREET,SHEL-967 ,E 98584
• 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
2 Horizontal setbacks per WAC246-272A-0210 must be maintained, unless prior approval is
obtained
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.
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OFFICIAL USE ONLY
DATE RECEIVED:
MASON COUNTY Le t:g-q >
COMMUNITY SERVICES AMOUNT RECEIVED: RECEIVEDB w (n
Public Health(Community Health/Environmental Health) C N
!gar 360-427-9670,ext.400 or 360-275-4467,ext.400 /� /�
415 N.6th Sheet-Shelton,WA 0-44 S VV _ _ 25 x
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ON-SITE SEWAGE TANK ONLY APPLICATION
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APPLICANT l PHONE m
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MAILING ADDRESS-STREET,CITY,STATE,ZIP CODE
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SITE ADDRESS-STREET,CITY,ZIP CODE •
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NAME OF DESIGNER PHONE I nY
NAME OF INSTALLER • PHONE
TYPE OF WORK select one) DRINKING WATER SOURCE 3 I d
❑ NEW CONSTRUCTION/UPGRADES REPlttft EPLACEMENT ❑ PRIVATE INDIVIDUAL WELL PRIVATE TWO-PARTY WELL Z
COMPONENT(S)TO BE REPLACED/INSTALLED ❑ PUBLIC WATER SYSTEM
SEPTIC TANK ❑PUMP TANK ❑RV HOLDING TANK BEDROOMS LOT SIZE? I�
❑ OTHER 3 3. Z 5 aC fes I
OTHER DETAILS(select all that apply) TANK(S)SETBACK CHECKLIST r
❑ SURFACING SEWAGE ❑EXISTING FAILURE 0 SHORELINE 6t1 100FT+PUBLIC/COMMUNITY WELLS n
SUBMITTALS 50FT+PRIVATE WELLS,SURFACE WATERS,STREAMS.RIVERS
d 1 0FT+DRINKING WATER SUPPLY LINES.e I!1,
LI PLOT PLAN(REQUIRED) CJ TANK CROSS SECTION(REQUIRED) �c
❑ PUMP DETAILS(IFAPPLICABLE) ❑ WAIVER(S)(IF APPLICABLE) 5FT+PROPERTY/EASEMENT LINES,FOUNDATIONS,FOOTINGS
PLOT PLAN CHECKLIST O I
"V PROPERTY LINES AND EASEMENTS 'd EXISTING/-PROPO3EB STRUCTURE EXISTING/PROPOSED OSS COMPONENTS AND LINES
WELLS WITHIN 100FT WATER SUPPLY LINES DRIVEWAYS!PARKING SURFACE WATERS,STREAMS,RIVERS,ETC... Iw
DIRECTION OF SLOPE)CONTOURS'EI PERIMETER/CURTAIN DRAINS NORTH ARROW SCALE BAR-
DIRECTIONS TO SITE AND SITE CONDITIONS:(ex.locked gate)
I w. I- h i≤ 3 w►a✓4y O1 11 ho► w —( •Cg., JE-� 9a�-� �s
Glo �ct) .Please., �-f-,¢% ,O )/Itr ��- �I aboutt oS�,Govtic4av rtIe e
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OFFICIAL USE ONLY BELOW THIS LINE
UPGRADE/FAILURE SOURCE(for reporting purposes)
❑VOLUNTARY ❑MAINTENANCE/PUMPING ❑BUILDING PERMIT ❑HOME SALE ❑COMPLAINT ❑OTHER:
COMMENTS!CONDITIONS O O
7ac f9!ac,eme,ri - JUN 29 2
SEWAGE TANKS MUST BE LISTED UNDER DOH"LIST OF REGISTERED SEWAGE TANKS'.TANKS MUST MEET CURRENT MINIMUM SIZE REQUIREMEI !EQ JIPPED1NPh�-
AND LIDS TO SURFACE,AND INCLUDE AN EFFLUENT FILTER(IF APPLICABLE). RECORD DRAWNG AND INSTALLATION REPORT REQUIRED FOR FINAL APPROVAL.
INSPECTOR SIGNATURE DATE APPLICATION EXPIRATION DATE APP N A OVED/ISSUED BY DATE
6i297 l zd .
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE REVISED 12/7 015
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EXCEED I(Y.CTCENTERTO GLITTER, . ��11 'FAhf,PERfGRATION,TI'P, W
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• Bob&•Anita Ha erman
• PO.Box 2842
• Poulsb'o WA 99371
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