HomeMy WebLinkAboutSWG2021-00122 - SWG As-Built - 3/12/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG-(';./-O€ ) Parcel # "19-33OS"000 .66
Applicant Name A,Vicert ,taw;/,'- /`pn,,-S Subdivision (Name/Div/Block/Lot)
Applicant Address /0.1-33 J' j Lh
City, State, Zip )3r40).e.i-hp,-) VA 9'5'3/1 Installer Name l--i.;,G / //;.r,'Qn
Site Address all N'6 L 4&_ fOr Designer Name
INSTALLATION CHECKLIST
0 Full System Installation Tank(s)Only 0 Drainfield Only 0 Repair ❑Other
System Type &ic 4/7 Pretreatment Type
>5 ft. from foundation? - N/A
>50 ft.from wells? - El YES El NO
>50 ft. from surface water? El ® El El ® El
Cleanout between building and tank? - 0 ® 0
o Tank baffles present? - - ❑ ® 0
d 24"access risers over each compartment?- El El El
y
Effluent filter installed? El ® El
Septic tank capacity (working) 00(7 gal Manufacturer i-lwe,r07401
0 D-box water level and speed levelers used? -
®- N/A ❑YES El NO
OO Manifold/D-box accessible from surface?- 0 0 0
QQ Check valves installed? 0
El
E Transport Line Size Schedule/Class
Bedrooms installed (check one) 0 2 0 3 0 4 0 5 0 6 0 Commercial/Other
>10 ft. from foundation?-
❑ N/A ❑ YES 0 NO
ca
>100 ft.from wells?
- 0
❑ ❑
>100 ft.from surface water? - 0
W 0 El
Z
>10 ft. from potable water lines?- - 0 0
0
CL > 5 ft. from property lines and easements? 0 ❑ 0
> 30 ft. from downgradient curtain/foundation drains? ❑ ❑
ci
Drainfield level and observation ports present - El
Graveless chambers or El Clean gravel used? (check one) ❑ El El
Proper cover installed over drainfield?- _ ❑ 0
0
Pump tank setbacks consistent with septic tank?- _ 0 N/A
0 YES ❑ NO
Pump tank capacity(flood) gal Manufacturer
< 24"access riser(s)and accessible from surface? 0 ❑ 0
t-
0. Alarm or Control Panel Installed? 0 0 0
Control Panel equipped with Timer/ETM /Counter- _ 0 0 0
Cl. Pump installed in ❑ Bucket or ❑ On Block or ❑ Other
a Pump Make/Model
g ❑ Floats or 0 Transducer
Tank draw down
C. in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at qpd
Updated 8/21/2018
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Mason County OSS Installation Report pg. 2 Parcel# 2330,1-.O0426
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - El YES
NO
If yes, please describe: Filed. axe. it er64
Were all components pumped out and properly abandoned per WAC246-272A-0300? - Eit YES El 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 S manifold orientation 8 layout,Septicfpump tank location,North arrow,reserve drainfield,existing and proposed buildings,location of wells,waterlines,
wells,observation ports,cleanouts.and other maintenance access points. Incomplete Record Drawings may create additional delays In final Installation approval and related permits.
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.
t3h
Si nature of Installer Date
Printed Name of Signee
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public
Health:
ry Signature of Environme al Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 8e1/2ot8
t ..
APPROVED .
MAR 1 2 2024
MASON COUNTY ENVIRONMENTAL HEALTH
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AMO..14 24.wasloa.....murk WA 58585 otsat.tom 22m710-00265 Printed From Mason County DMS
Rinted from Mason County DMS