HomeMy WebLinkAboutSWG2022-00091 - SWG As-Built - 6/12/2024 Mason County OSS Installation Report pg. t MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 'ZO 22 — C,elDII Parcel # 3191H7- 3va06U
Applicant Name "n . flan �h Subdivision (Name/Div/Block/Lot)
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Applicant Address f S33"S tta.rm- �)a£w or SF.
City, State, Zip Velma, kn)Q 18597 Installer Name R., �a\abet - SNUB (,,.,SFr t��•
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Site Address Designer Name Ada>~ {✓<.ak' -
INSTALLATION CHECKLIST
Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑Repair ❑Other
System Type f .Ss� rk, Pretreatment Type 61o.Ja4t�
>5ft. from foundation? - - - - -- - - - - - - -- - - - - - - - - - - - -- ❑ NIA I&YES NO
>50 ft.from wells? - - -- - - - - - - - - El ❑
Y >50 ft.from surface water? - - - - ��� �� -- - - ❑ ❑
Z
H Cleanout between building and to - I-] ]CU�4 - ❑ ❑
U Tankbaffles present? -- - - - - - - - - -- - - - ❑ ❑
24"access risers over each comp rgnent?- -tt� - - - - --- - - ❑ ❑
WEffluent filter installed?- - -- - - - y - --- - -- - -- ® ❑ ❑
N
Septic tank capacity (working) IZoO gal Manufacturer Nu QaFtr i5NK SOo
0 D-box water level and speed levelers used? - -- - - - - -- - - - - 18N/A ❑ YES NO
0J
0 Manifold/D-box accessible from surface?- -- - -- - - --- - - - - - - ❑ $I ❑
°?Z Check valves installed? - - - - - - - - - - - - - - - - - - - - - - - - -- ❑ ® ❑
2 Transport Line Size 2' Schedule/Class SCh q 0
Bedrooms installed (check one) ❑ 2 K3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft,from foundation?- - ❑ NIA YES ❑ No
G >100 ft. from wells? ❑
W >100 ft.from surface water? - - - - - - - - - - - - - ❑ ® El
LL >10 ft.from potable water lines? - - - - - - - - - - - - - - - - - - - - - ❑ 10 ❑
Q¢ >5 ft.from property lines and easements? - ❑ ❑
K > 30 ft.from downgradient curtain/foundation drains? - - - - - - - - - - ❑ ❑
Drainfield level and observation ports present - - - - - - - - - - - - -- ❑ � ❑
Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - - - - - - - - - - - - - -- - - ❑ ❑
Pump tank setbacks consistent with septic tank? ❑ NIA YES ❑ NO
Y Pump tank capacity(flood) IZS° gal Manufacturer li`ue'grecn�ff.[4�,F'
Q24"access risers)and accessible from surface? ❑ '� El~ Alarm or Control Panel Installed. ❑ ❑
`t Control Panel equipped with Timer/ ETM/Counter ❑ ❑
a Pump installed in ❑ Bucket or P On Block or ❑ Other
a Pump Make/Mot lZo¢lle� lN)SZ Floats or� ❑ Transducer
y Tank draw down Z 5 in/min Pump capacity (Po gpm Squirt Height�ft
Pump on time L Min u k L Pump off time cwr S Daily Flow set at D0 gpd
ueaeiea eivrzaie
Mason County OSS Installation Report pg. 2 Parcel tt 3 i 9 ly L �06 ODC7
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? ❑ YES 19 NO
If yes, please describe:
Were all components pumped out and property abandoned per WAC246-272A-0300? -- - - -- -- ❑ YES - ❑ NO
RECORD DRAWING
This is a permanent record and most be accurate and des arire ive enough to rNoute In the need of maintenance activities and future development Typical Record
finished-.am field Full x nomfind mahound&layout,seprnmump tank location,north snow,nosoe traineld,eaielMg and proposed modmgs.IccaAon of wells,walrmar,
walls,observation pods,doormats,and other mandename,access poinls. Incomplale Remd Drawings may ueale eddNorad delays In final haddeGon 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.
Signature oflnstaller Date
Printed Name of Signee r
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
;r
Record Drawing on behalf of Mason County Public
Health
Signature of Emaddinmenti Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE eladandrprodle
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