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Home My WebLink AboutRESERVE ONLY - SWG Letters / Memos CLEAR FORM Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SwG Parcel# 321225000097 Applicant Name Eric& Hannah Landsverk Subdivision (Name/Div/Block/Lot) Applicant Address 19409 76th AVE W Lake Limerick 3, lot 97 City, State, Zip Lynwood, WA 98036 Installer Name Site Address 2140 E Saint Andrews DR N Designer Name R. Thomas Purdum INSTALLATION CHECKLIST ❑ Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑ Repair •Other Reserve Only System Type Pretreatment Type >5 ft. from foundation? ■ N/A ❑ YES ❑ NO >50 ft. from wells? - 101 ❑ ❑ Z >50 ft. from surface water? - . ❑ ❑ H Cleanout between building and tank? ❑ ❑ U Tank baffles present? . 0 ❑ d 24"access risers over each compartment?- I♦ ❑ ❑ W Effluent filter installed? . ❑ ❑ to Septic tank capacity (working) gal Manufacturer O D-box water level and speed levelers used? - . N/A ❑ YES ❑ NO 00 Manifold/D-box accessible from surface? 1111 ❑ ❑ mZ Check valves installed? - IN ❑ ❑ Oct f Transport Line Size Schedule/Class Bedrooms installed (check one) ❑ 2 3 ❑4 0 5 ❑6 ❑Commercial/Other >10 ft. from foundation?- ❑ NIA El YES ❑ NO O >100 ft. from wells?- ❑ E ❑ W >100 ft. from surface water? - ❑ MI ❑ it >10 ft. from potable water lines? ❑ E ❑ QZ > 5 ft. from property lines and easements? ❑ E ❑ R > 30 ft. from downgradient curtain/foundation drains? - ❑ MI ❑ O Drainfield level and observation ports present - II ❑ ❑ ❑ Graveless chambers or ❑ Clean gravel used? (check one) Proper cover installed over drainfield? M ❑ ❑ Pump tank setbacks consistent with septic tank? INI N/A ❑ YES ❑ NO • Pump tank capacity(flood) gal Manufacturer < 24"access riser(s) and accessible from surface?- . ❑ ❑ ~ Alarm or Control Panel Installed? ® ❑ ❑ a 2 Control Panel equipped with Timer/ETM/Counter- El ❑ ❑ 7 a Pump installed in ❑ Bucket or ❑ On Block or ❑ Other a 0 Pump Make/Model ❑ Floats or ❑ Transducer a Tank draw down in/min Pump capacity qpm Squirt Height ft Pump on time Pump off time Daily flow set at gpd Updated 832112018 Mason County OSS Installation Report pg. 2 Parcel# 321225000097 ABANDONMENT RECORD Were existing septic components abandoned as part of this project? - ❑ YES Q NO If yes, please describe: Were all components pumped out and property abandoned per WAC246-272A-0300? ❑ YES Q NO RECORD DRAWING This is a permanent record and muat be accume and descriptive enough to re-locate In the need of maintenance activities and future development. Typical Record Drawings contain. Dnmgeld a manifold onentation a layout.sspnupump tank locaom.Not arrow.reserve drainfield,existing and proposed buildings,location or wells,waterlines, wells,observation pods,ueanows,and other maintenance access points. Incomplete Record Drawings may create additional elays in final nsbuation approval and related permits la Record Drawing Attached CERTIFICATION OF INSTALLATION INSTALLER DESIGNER/ENGINEER I certify that I 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. i S i S Signature of Installer Date ice ' S I'. . . =.. ✓ Printed Name of Signed jI (- ;= yk MASON COUNTY PUBLIC HEALTH Aga' 1.1 The undersigned approves this Installation Report and i ? R.i^omoa 129Purdum s Record Drawing on behalf of Mason County Public LICENSED(ESiGNERlook Health: EXPIRES 2/07/2025 10/15/2023 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 Updated90]Qg18 il II 511 | - ; � . . . : t \ : » : y. \ y y• ° y 10. | CO Li al P OD 00 : - - - - k•; [.qk A z 0 ES «® :, | : & + i- - ! _: ; A 41i J \ x \Q\\ - . �. _ w_ \ ow (Los o | § ■/ &@ ) $ ƒ «�\ ` ,» /\ ( \ U0 / ° 9 § § � « ` k \ i . Aid\, Z( ` % / | ƒ | $ §/ ` ww / ` k § | g/ ! R C \