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HomeMy WebLinkAboutSWG2026-00308 TANK ONLY - SWG Application / Design - 9/16/2026 MASON COUNTY 415 N111 6TH STREET,SFiEL-967 WA 98584 SHELTON:360-427-9670,E~XT 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: SWG2026-00308 OWNER SOUTHERLAND ET UX MICHAEL A Phone: Address: EILEEN K KRONQUIST ALLYN, WA 98524 APPLICANT SOUTHERLAND ET UX MICHAEL A Phone: Address: EILEEN K KRONQUIST ALLYN, WA 98524 APPLICANT MIKE SUTHERLAND Phone: 360-731-3958 Address: 241 E NELSON RD ALLYN, WA 98524 SEPTIC INSTALLER Jon Johnson* Phone: 360-340-1679 Address: 50 NE Peninsula blvd LOUISVILLE, KY 40223 Site Address: 241 E NELSON RD Primary Parcel Number: 122294400050 Permit Description: Replace failed pump tank with Roth 1250 gallon Permit Submitted Date: 09/16/2026 Permit Issued Date: 09/17/2026 Issued By: Rhonda Thompson Current Permit Fees Paid: $275.00 (additional fees may be required upon installation of system). Permit Expiration Date: 09/17/2027 (based on date of inspection) Type of Work OSS Repair Components being Replaced: Pump Tank Only Surfacing Sewage? No Existing Failure? Yes Shoreline? No Horizontal Setbacks Met? Yes Number of Bedrooms: 4 Drinking Water Source: Private Well/Spring Additional Details: Roth 1250g pump tank Permit Conditions: 2 Horizontal setbacks per WAC246-272A-0210 must be maintained, unless prior approval is obtained 4 Mason County Asbuilt Form, Record Drawing, and installation fee must be submitted for final installation approval. 3 Permit must be installed by a Mason County Certified Installer unless prior written authorization from Mason County is obtained. I Approval of this septic permit does not approve the building location. Building location is subject to approval from all applicable departments and regulations. 5 Proposed development subject to zoning requirements and approval by the planning department staff per Mason County Title 17. 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/onsiteloss-inspection-request.php or call: 360-427-9670, extension 400. OFFICIAL USE ONLY DATE RECEIVED: MASON COUNTY It c C N COMMUNITY SERVICES AMAOUNTRE�E _ RECEIVE W (j) v M Public Health (Community Health/Environmental Health) 360-427.9670,e.t 400 or 360-275-4467,eat.400 ^ 415 H.6th Sveet-Shelton,EtA 93584 C W G ,�© -- J Z N ON-SITE SEWAGE TANK ONLY APPLICATION APPLICANT PHONE Pll Ill r Mike Sutherland 360 731-3958 z MAILINOADDRESS-STREET,CITY,STATE,ZIP CODE 241 E Nelson Rd Allyn Wa 98524 M SITE ADDRESS-STREET,CITY,ZIP CODE 1 same NAME OF DESIGNER PHONE I Jon Johnson 360 340-1679 NAME OF INSTALLER PHONE Ni Jon Johnson C N TYPE OF WORK(sefectone) DRINKING WATER SOURCE O ❑ NEW CONSTRUCTION I UPGRADES J REPAIRI REPLACEMENT I] PRIVATE INDIVIDUAL WELL ❑ PRIVATE TWO-PARTY WELL Z COMPONENT(S)TO BE REPLACED/INSTALLED ❑ PUBLIC WATER SYSTEM ❑ SEPTIC TANK I PUMP TANK ❑ RV HOLDING TANK BEDROOMS LOTSIZE J -P ❑ OTHER 4 1.6 acre OTHER DETAILS(se;acf aftthat apply) TANK(S)SETBACK CHECKLIST Q ❑ SURFACING SEWAGE I]EXISTING FAILURE ❑SHORELINE I] 100FT+PUBLIC/COMMUNITY WELLS n t SUBMITTALS IN 50FT+PRIVATE WELLS,SURFACE WATERS,STREAMS,RIVERS 0 PLOT PLAN(REQUIRED) IN TANK CROSS SECTION(REQUIRED) ❑' 10FT+DRINKING WATER SUPPLY LINES O ❑ PUMP DETAILS(IF APPLICABLE) ❑ WAIVER(S)(IF APPLICABLE) I7 5FT+PROPERTY/EASEMENT LINES,FOUNDATIONS,FOOTINGS PLOT PLAN CHECKLIST d + C) I7 PROPERTY LINESAND EASEMENTS IN EXISTING/PROPOSED STRUCTURES I I EXISTING/PROPOSED OSS COMPONENTSAND LINES ❑ WELLS WITHIN 100FT I] WATER SUPPLY LINES ( DRIVEWAYS/PARKING 0 SURFACE WATERS,STREAMS,RIVERS,ETC... I (T1 0 DIRECTION OF SLOPE/CONTOURS 0 PERIMETER/CURTAIN DRAINS ❑ NORTHARROW 0 SCALE BAR DIRECTIONS TO SITE AND SITE CONDITIONS:(ex.locked gate) From Allyn heading north on hwy3 Left on grapeview loop rd Left on nelson rd OFFICIAL USE ONLY BELOW TI-iIS LINE UPGRADE 1 FAILURE SOURCE(for reporting purposes) ❑VOLUNTARY ❑MAINTENANCE/PUMPING ❑BUILDING PERMIT ❑HOME SALE ❑COMPLAINT ❑OTHER: COMMENTS?CONDITIONS Q6Q Q SEWAGE TANKS MUST BE LISTED UNDER DOH"LIST OF REGISTERED SEWAGE TANKS'. TANKS MUST MEET CURRENT MINIMUM SIZE REQUIREMENTS,EQUIPPED WITH RISERS AND LIDS TO SURFACE,AND INCLUDE AN EFFLUENT FILTER(IF APPLICABLE). RECORD DRAWING AND INSTALLATION REPORT REQUIRED FOR FINAL APPROVAL INSPECTOR SIGNATURE DATE APPLICATION EXPIRATION DATE APPLICATION APPROVEDI ISSUED BY DATE THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE REVISED 4 2/7120 1 5 9vvc-z9v (09E)euo&d ST[BISa �S i Ln G$ 1 34?yJ.1pJ L± J �be � O I I a Y w C] 0O p \ 7-X N z �L . 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