HomeMy WebLinkAboutSWG2026-00228 - SWG Application / Design - 7/22/2026 MASON COUNTY 415"B SHSTREET SHELTO70,EXT 400
SHELTON:360-027-96]0,EXT 400
BELFAIR:360-275-4467,EXT 400
Public Health & Human Services ELMA:360-082-5269, EXT 400
I_IFAX:360-027-7787
On-Site Sewage System Permit: SWG2026-00228 C'0
APPLICANT BRACKEN RODNEY W&SHERRY Phone: 360-490-7887
0
Address: 1768 N THREE FEATHERS DR GREEN VALLEY, AZ 85614
OWNER BRACKEN RODNEY W&SHERRY Phone: 360-490-7887
Address: 1768 N THREE FEATHERS DR GREEN VALLEY, AZ 85614
SEPTIC DESIGNER MICAH HALVERSON' -Olympic Phone: 360-490-6365
Construction
Address. PO BOX 698 ELMA, WA 98541
SEPTIC INSTALLER WES GRAVES* Phone: 360-490-9428
Address: PO BOX 1460 SHELTON, WA 98584
Site Address: 50 W White Rd
Primary Parcel Number: 420364100060
Permit Description: Repair: SFR 4-bedroom gravity system with Class B Waiver
(WA12026-00061)
Permit Submitted Date: 07/22/2026
Permit Issued Date. 08/1312026
Issued By: David Anderson
Current Permit Fees Paid: $845.00 (additional fees may be required upon installation of system)
Permit Expiration Date: 08/0612027 (based on date of lospecoom
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 Drain field installation not to exceed designed upslope and downs lope 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.
THIS PERMIT MUST BE ONSITE DURING INSTALLATION OF O55.
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/environmentallonsiteloss-inspection-request.php or call:
360-427-9670, extension 400.
MASON COUNTY 415N6TH X
ELTON. 0427-970,ET 400
SHELTON:360-02]-96]0,ET 400
IJj BELFAIR:360-275-4467,EXT 400
Public Health & Human Services ELMA:3604825269,EXT 400
FAX'.360-427-7787
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/environmentallonsite/oss-inspection-request.php or call:
360-427-9670, extension 400.
- . OFFICIAL'USE ONE Y
MASONCOUNTY FDA�RECH�D, cl� I EIV ' PECEYEOBV:ED Public Health & Human Services � J pp,y c wEnvronmental Health 36U427-9670,ett.4Wor36D2754467,e5.4W 415N.6th SU eet-Shelton,WA9B584 G — w O
M� 2 N
ON-SITE SEWAGE SYSTEM APPLICATION > z
mn
APPLICANT PHONE m
r
Rodney & Sherry Bracken _ 360-490-7887 c
MAILING ADDRESS-STREET Cl STATE. IP-CODE -J -„ +
50 W White Rd Shelton Wa 98584 z
SITE ADDRESS-STREET.CITY ZIP LOU' 4.
Same as mailing �,. a
PHONE
NAME OF DESIGNER _/` :( I ro
Micah Halverson 360-490-6365
NPME OF INSTALLER PHONE a O
AAA < Iw
PERMIT TYPE(se'ed ore) DRINKING WATER SOURCE
rN RESIDENTIAL OsS r1 COMMUNITY OSD flCOMMEt1a OSS (I PRIVATE INDIVIDUAL WELL ❑ PRIVATE TWO-PARTY WELL Z 0)
PUBLIC WATER SYSTEM
TYPE OF WEEK OW oile)
rl NEW CONSTRUCTION I UPGRADED IVI REPAIR I REPLACEMENT OTHER DETAILS(select that apply) ❑ TABLE X REPAIR Ia
SUBMITTALS m SURFACING SEWAGE EXISTING FAILURE 0 SHORELINE
DESIGN FORM REQUIRED) IA SEPTIC DESIGN REQUIRED) BEDROOMS I LOT SIZE WAS LOT CREATED AFTER 4n2DST r-
0 1
4 WAIVER(S)(IF APPLICABLE) 4 5.3ac ❑ YES Q NO 0 I O
DIRECTIONS TO SITE AND SITE CONDITIONS.(ex bckM gate)
Contact owner for access, locked gate I o
o to
IIn
SITE MOST SE FLAGGED FROM MAIN ROAD AND TEST HOLES MV.IBE FLAGGED M PESTHOLE NUMBERS. I O
- . —.. --- — OFFICIAL USE ONLY BELOWTHIS LINE - -- - '- —
UPGRADE I FAILURE SOURCE(for reoo'11ng purposes)
❑VOLUNTARY OMAINTENANCEJPUMFING ❑BUILDING PERMIT DHOME SALE ❑COMPLAINT OOTHER.
?o7 INSPECTOR SOIL LOGS COMMENTS/CONDITIONS
r�OO' 9k fc,dntu�f tr �cti)
,cast- of 3y" M cc»>n
;,Y, etao -35' 45c l'jPt 4)
(551- A 351 `H (, r
Ito -j6 4$L fief} c1t 3Q t/ CP ntj' .
t4:Ø 3`i' (75L
Rc s,i q l- 3'j ' w/ Cot,n
RECORD DRAPING AND INSTALLATION REPORT
SOIL CODES:
V=VERY G=GRAVELLY S=SAND L=LOAM S„SILT C=CLAY E=EXTREMELY fl=ROOTS REQUIRED FOR FINPLAPPROVAL.
INSPEOTO IGNARIRE Y V 1 70Z�DATE APPLICATION E�OXPIRA�N0 E A PP ONPPPRO ISSUED ?o DAl£
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE of-// Revised:4/1412025
DESIGN FORM—PAGE ONE Assessor's Parcel Number: 4 2 0 3 6 - 4 1 - 0 0 0 6 0
A design will be reviewed when 3 copies of each of the following are submitted:
v Completed design form that has been signed and dated. 0 Scaled layout sketch, including all applicable items on checklist.
v 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: SW G J-U3Sp - C -)- --t_ Designer's Name: Micah Halverson
Applicant's Name: Rodney&Sherry Bracken Designer's Phone Number: 360-490-6365 __
Mailing Address:
50 W White Rd Designer's Address: PO Box 1519
_.. _
Shelton Wa 98584 City State Lip Shelton Wa 98584
City State Zip Designers Email halversondesignllc@outlookp
DESIGN PARAMETERS
Treatment Device
0 Glendon ❑ Sand Filter ❑ Mound ❑Sand Lined Drainfield ❑ Recirculating Filter ❑ATU U Othero'tten.Zone
Treatment Level (check all that apply): 0 A ❑ H ❑ C ❑ BL I ❑ 131.2 ❑ BL3 ri1 E ❑N
Drainfield Type
Gf Gravity ❑ Pressure fi'f Trench ❑ Bed ❑ Sub Surface Drip
Septic Tank/Drainfield Specifications Laterals
Number of Bedrooms 4 Schedule/Class ASTM 2729
Daily Flow: Operating Capacity 360 gpd Length 45 _ ft
Daily Flow: Design Flow 480 gpd Diameter 4 in
Septic Tank Capacity(working) Existing1200 gal Number 6
Receiving Soil Type(1-6) 4 - Separation 6 + ft
Receiving Soil Appl. Rate -6 gpd/ft2 Orifices
Required Primary Area 800 P12 Total Number of Orifices Perf
Designed Primary Area 810 & Diameter in
Designed Reserve Area 810 ft2 Spacing in
Trench/Red Width 3 ft Manifold
Trench/Bed Length 270 ft Schedule/Class D-Box
Elevation Measurements Length ft
Original Drainfield Area Slope 9-13 % Diameter in
New Slope, If Altered same % Preferred manifold configuration used? 0 Yes R'No
Depth of Excavation Up-slcpc 16 Max in Transport Pipe
from Original Grade Dawn-slope 6 Min in Schedule/Class ASTM3034
Designed Vertical Separation 18+ in Length 78 ft
Gravel-based Drainfield Required? Ed Yes 0 No Diameter 4 in
Pump Required? 0 Yes RfNo Dosing and Pump Chamber
Pump/Siphon Specifications Number of doses/day Gravity
Diff, in Elevation Between Pump& Uppermost Orifice_ft Dose quantity gal
Drainfield Squirt Height/Selected Residual(head) ft Chamber Capacity(Rood) gal
Uppermost Orifice 0 Higher 0 Lower than Pump Shutoff
Pump controls:Please check those required.
Capacity @ Total Pressure Head gpm 0 Timer ❑ Elapse Meter 0 Event Counter
Calculated Total Pressure Head ft If Timer: Pump on ,Pump off
Comments
Contact Owner for Access
Revised:4/14/2025
DESIGN FORM—PAGE TWO Assessor's Parcel Number:4 2 0 3 6 -- II -- 0 0 0 6 0
Permit Number: SWG ,) Cf�
DESIGN CHECKLISTS
Scaled Plot Plan Scaled Layout Sketch Cross-Section Sketch
RJ Test hole locations 9 Drainfield orientation and layout Reference depth from original grade:
la Soil logs 56 Trench/bed dimensions and Rf Septic tank
� Property lines
critical distances within layout lZ Drainfield cover
m Existing and proposed wells 66 D-Box/Valve box locations Reference depth from original grade
within 100 ft of property IZ Septic tank/pump chamber and restrictive strata:
Measurements to cuts,banks, and locations 19 Laterals,trench/bed,top and
surface water and critical areas 19 Observation port location bottom
m Location and orientation of [9 Clean-out location O Curtain drain collector
curtain drain and all absorption &J Manifold placement ❑ Sand augmentation
components [9 Orifice placement Other cross-section detail:
Location and dimension of R1 Lateral placement with distance 56 Observation ports/clean-outs
primary system and reserve area to edge of bed Other Information
66 Buildings R1 Audible/visual alarm referenced Yes No
16 Direction of slope indicator G6 Scale of drawing shown on scale if ❑ Design staked out
9 Waterlines bar ❑ Rf Recorded Notices attached
Ed Roads,easements,driveways, p Elevation benchmark and relative l ❑ Waiver(s)attached
parking elevations of system components ❑ Z Pump curve attached
� North arrow and scale drawing
Cd ❑ Evaluation of failure
shown on scale bar Non-residential justification
❑ ❑ Waste strength
❑ ❑ Flow
DESIGN APPROVAL
The undersigned designer must be notified by installer
r at time of installation &f Yes O No
it a,tt CL�I/PA m- 7,2/ w24
Signature of Designer Date
The undersigned has reviewed this design on behalf of Mason County Public Health and deEr t be in
compliance with state and local on gulations: / 0..A"V
Environmental alth Specialist Date��-y,„ t�
CAUTION: DESIGN APPROVAL IS VALID ONLY UNDER THE FOLLOWING GOtDfl'K'FN't.`^
✓ 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
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Mailing:50 W.White Road
PO Box 1519 Shelton Wa 98584 shelmnwa96s64 50 W. White Road
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PO Box 1519 Shelton Wa 98584 B g Sheuo White
8584
50 W. White Road 3
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