HomeMy WebLinkAboutSWG2023-00084 - SWG As-Built - 5/16/2023 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT I FORMATION
Permit Number SWG 2023 000c 4 Parcel # Co V l a 2 3 200050
Applicant Name LAQ-p- Q Subdivision (Name/Div/Block/Lot)
Applicant Address *SCA 15 ALLCt,) V-0 3 t._) -A
City, State, Zip VZO'1 WA (AbS-bo Installer Name 514.1l.11v£R- cO15 T70...7
Site Address es S f-tvr.1/76 4I VtDesigner Name gP.-4,c---?..JSCf-AA---
. IINSTALLATIQN.CHECKLIST - .
(Full System Installation 0 Tank(s)Only 0 Drainfield Only ❑Repair ❑ Other
System Type?"g-055t17-1.— 54v 9 3C—C2'\ Pretreatment Type ,t7/4
>5 ft. from foundation? - 4 ---- cz N/A ❑YES ❑ NO
>50 ft. from wells? _ __._ ❑ El. ❑
Z >50 ft. from surface water? - -- - - - ❑ ® ❑
• Cleanout between building and tank? - - - - - - --- -6--. - 0 IQ El
z3 Tank baffles present? - ¶ ❑ ❑
a24"access risers over each compartment?- --- - - -- -c�� - ❑ ® ❑
Effluent filter installed?- ill
® ❑
Septic tank capacity(working) t ZCee gal Man• rer /'1Dd �j)10)'i•1c.P-S ces -,
C.� D-box water level and speed levelers used? - - )4 N/A ❑ YES 0 NO
m0 Manifold/D-box accessible from surface?- - I. ❑ 0
Z Check valves installed? - ❑ lE10
CZ cc
2 Transport Line Size Z' lt- Schedule/Class 4/4
Bedrooms installed (check one) ❑ 2 I3 ❑4 0 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- - 0 NIA ❑ YES ❑ NO
a >100 ft.from wells?- - 0 B. 0
W >100 ft. from surface water? - - ❑ El
EC >10 ft.from potable water lines?- - ❑ El 0
Z > 5 ft. from property lines and easements?- 0 ® ❑
a -
tL' > 30 ft.from downgradient curtain/foundation drains? - - 0 0 0
Drainfield level and observation ports present - - ❑ E] ❑
Sa Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - 0 E. 0
Pump tank setbacks consistent with septic tank? - - 0 N/A IZI YES 0 NO
Y Pump tank capacity(flood) li 00 gal Manufacturerf4O0tL 7402-5 C'.}s -
24"access riser(s)and accessible from surface?- - ❑ k 0
p-
a. Alarm or Control Panel Installed? - - 0 El ❑
• Control Panel equipped with Timer i ETM/Counter- - ❑ 1:El. 0
D. Pump installed in 0 Bucket or Fq.On Block or ❑ Other
a' Pump Make/Model L 03 T'`-/ Z$O jZ3 Floats or ❑ Transducer
2
4. Tank draw down 1.-- in/min Pump capacity 0 -5 gpm Squirt Height 2-r Z�� ft
i
•
Pump on time 2 • Mf,J Pump off time V hi--(2— Daily flow set at 3(,O gpd
Updated 6J21r2018
Mason County OSS Installation Report pg. 2 Parcel II ta\A O 32or , ,o
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? • - YES KJ NO
If yes. please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? - YES IZ 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 corlain Drainfield&manifold orientation&layout:Seplicfpump tank location.North arrow,reserve drainfield.existing and proposed ouildings,location of wells,waterlines,
wells,observation ports,deanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays in final installaton approval and related permits.
Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER!ENGINEER
I certify that l 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 Dra ng is accurate.
A - t — 23
Signature of installer Date ,, t.,P
C- ftk i�— S K l i` t4 E. —
,`�.t•of w�sy ,tn
Printed Name of Signee
•
MASON COUNTY PUBLIC HEALTH • -41
The undersigned approves this Installation Report and ? .5100183
Record Drawing on behalf of Mason County Public ERIC R. RUSSELL
Health: LICENSED DR
40k/ V16 /23 FFXPIRES 112102I9...S` I
Signature of Environment I Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updawd B/21t2018
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