HomeMy WebLinkAboutSWG2022-00071 - SWG As-Built - 7/20/2022 (2)somiw
Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2022-00071 Parcel # 42032-33-00010
Applicant Name Nicole &Adam Pugh Subdivision (Name/Div/Block/Lot)
Applicant Address 1651 W Gallagher Rd
City, State, Zip Shelton, Wa 98584 Installer Name Jamie Workman
Site Address Same Designer Name Micah Halverson
INSTALLATION CHECKLIST
0 Full System Installation ❑ Tank(s)Only ❑ Drainfield Only ❑ Repair ❑ Other
System Type NuWater to Pressure Trench Pretreatment Type BNR-500
>5 ft. from foundation? - - ❑ N/A ❑■ YES ❑ NO
>50 ft. from wells? - •- ❑ 0 ❑
Z >50 ft. from surface water? - - ❑ I
HCleanout between building and tank? - - ❑ IC
V Tank baffles present? - - ❑ 0 ❑
f— 24" access risers over each compartment?- - ❑ 0 ❑
a
W Effluent filter installed?- - ❑ ❑ ❑
fn
Septic tank capacity (working) 500+NuWater gal Manufacturer Sound Placement
�0 D-box water level and speed levelers used? - - 0 N/A ElYES ❑ NO
QO Manifold/D-box accessible from surface?- - ❑ III
0o Z Check valves installed? - - ❑ ® ❑
❑Q
2 Transport Line Size 2" Schedule/Class 40
Bedrooms installed (check one) ❑ 2 0 3 __0.4___ ❑-5;S • ❑Commercial/Other
>10 ft. from foundation. - ' is 'I-A �L.
�' I}m-!b- -L —L,1` ❑ N/A ® YES ❑ NO
CI >100 ft. from wells?- 4 L V -+I ❑ ® ❑
W
>100 ft. from surface water? - I� _JUL, 1�_2022- - ❑ 0 ❑
Li >10 ft. from potable water lines?- ,f� ❑ 00
> 5 ft. from property lines and easements?- f3y �{ -- ❑ PI ❑
> 30 ft.from downgradient curtain/foundation drains? - - IR ❑ ❑
o
Drainfield level and observation ports present - - ❑ II ❑
❑ Graveless chambers or [U Clean gravel used? (check one) •
Proper cover installed over drainfield?- - ❑ II ❑
Pump tank setbacks consistent with septic tank? - - ❑ N/A ® YES ❑ NO
• Pump tank capacity (flood) 1233 gal Manufacturer Sound Placement
< 24" access riser(s) and accessible from surface?- - ❑ I ❑
H
a Alarm or Control Panel Installed? - - ❑ 0 ❑
2 Control Panel equipped with Timer/ ETM /Counter- - ❑ 0 ❑
m
a. Pump installed in 0 Bucket or ❑ On Block or ❑ Other
a• Pump Make/Model Zoeller 145 0 Floats or ❑ Transducer
a Tank draw down 3 in/min Pump capacity 60 gpm Squirt Height 6.5 ft
Pump on time 1:15 min Pump off time 6 hrs Daily flow set at 300 gpd
Updated 8/21/2018
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Mason County OSS Installation Report pg. 2 Parcel# 42032-33-00010
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - 11 YES ❑ NO
If yes, please describe:Abandoned old septic tank and drainfield
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - ❑ YES ❑ NO
RECORD DRAWING
This Is a permanent record and must be accurate and descriptive enough to re-locate In the need of maintenance activities and future development. Typical Record
Drawings contain: Drainfield&manifold orientation&layout,Septic/pump tank location,North arrow.reserve drainfield,existing and proposed buildings,location of wells,waterlines,
wells,observation ports,deanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays in final installation approval and related permits.
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❑ Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER] ENGINEER
1 certify that 1 installed the system in accordance with I certify that the system has been installed in accor-
the septic design stamped "APPROVED"by Mason dance with the septic design stamped `APPROVED"by
County Public Health and that any deviations shown Mason County Public Health and that any deviations
here have been cleared/approved by both the designer shown here have been cleared/approved by both
and Mason County Public Health and meet all State myself and Mason County Public Health and meet all
and Mason County Codes. State and Mason County Codes
I further certify that all information contained on this I further certify that all information contained on this
form and attached Record Drawing is accurate. form and attached Record Drawing is accurate.
7- i
Signature of Installer Date Zo
Printed Name of Signee '1 � '
MASON COUNTY PUBLIC HEALTH -1~ 4-11 Y s
The undersigned approves this Installation Report and
5100409
Record Drawing on behalf of Mason County Public rff.UCJIMTNMMELHALVERSON
LICENSED DIESiGNER <
Health:
1/1'1 �/7 Uf a- z-
Signature of Environmental Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 8121I2018
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M.Halverson Design LLC Applicant/Owner: Property Info: #42032-33-00010 SHEET~ ""`.:
'i n dx t• CountylOtttl4: ADAM 1651 W GALLAGHER RD 1
Halverson esi n lc • ou ooTc.com SHELTON, WA.98584 REVISION X.
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