HomeMy WebLinkAboutSWG2021-00660 - SWG Application / Design - 5/6/2022 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 7(-2.:Z — CEO(pV) Parcel #_5-70 q -75-On I 0 0
Applicant Name Aikrs . L.eMC...Kt Subdivision (Name/Div/Block/Lot)
Applicant Address PC 5c)e --( (v
City, State, Zip apit Vo._t -ey'1,61, C1g03 g Installer Name M-:v.e Lac -e c-c, ,x,k4111L
Site Address 7g-Z W. LI-U-0/taki,d-Zc ( Designer Name --\c\ 'CS VIA-e c+:X4
INSTALLATION CHECKLIST
Cg Full System Installation 1::] Tank(s) Only ❑ Drainfield Only ❑ Repair ❑Other
System Type rr=PS'SCA. Pretreatment Type
>5 ft. from foundation? - , , - -- } N/A rzYES ❑ NO
>50 ft. from wells? - V[' t r' 1 tl' - ❑
Z >50 ft. from surface water? - -Ida --'- M ❑
I C
leanoutbetweenbudingandtank? - - - - - - ❑ ❑
U
Tank baffles present? - - - -- [] 2' ❑
a24" access risers over each compartment? - - - By - ❑ ($r ❑
W Effluent filter installed?- - ❑ � CI�^� (
Septic tank capacity (working) /200 gal Manufacturer
0 D-box water level and speed levelers used? - - EN.N/A ❑ YES ❑ NO
oO Manifold/D-box accessible from surface?- - CI ❑
mz Check valves installed? - - ❑ 2 ❑
pQ 7 '
IE Transport Line Size Schedule/C-Fass `-tv
Bedrooms installed (check one) ❑ 2 14'3 ❑4 ❑ 5 El 6 El Commercial/Other
>10 ft. from foundation?- - ❑ N/A EYES ❑ NO
o >100 ft. from wells?- - ❑ tRi. ❑
W >100 ft. from surface water? - - ElEd ❑
LL >10 ft. from potable water lines?- - ❑ 1:0 ❑
Z > 5 ft. from property lines and easements?- - ElRi. CI
12 > 30 ft. from downgradient curtain/foundation drains? - - ❑ N. ❑
ci
0 Drainfield level and observation ports present - - ❑ In ❑
❑ Graveless chambers or CO Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ El ❑
Pump tank setbacks consistent with septic tank? - - ❑ N/A w YES ❑ NO
• Pump tank capacity (flood) `7-75" gal Manufacturer 5-PS
< 24" access riser(s) and accessible from surface?- - ❑ Ni. ❑
F-
a Alarm or Control Panel Installed? - - ❑ CI CI
E Control Panel equipped with Timer/ETM/Counter- - ❑ Ed. 0
c fy
n- Pump installed in ❑ Bucket` or ❑ On Block or ,�Zf Other S'�c \ k�c,�� k,� OC��cef
a• Pump Make/Model L,' ci ' Z43n 0 Floats or ❑ Transducer
a R Tank draw down Z in/min Pump capacity Lk, gpm Squirt Height 76 --ft--
Pump on time /mi ^..l, 5(,) .Sec Pump off time 6 ,A0t-4-,- Daily flow set at Z--76 qpd
Updated 8r21r2018
Mason County OSS Installation Report pg. 2 Parcel# 52-0014 7s- 00IOC)
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - ❑ YES NO
If yes, please describe:
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,cleanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays in final installation approval and related permits.
fig Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
I certify that I installed the system in accordance with 1 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 attaehedRecord Dr ' 's accurate. form and attached Record Drawing is accurate.
ignature of Installer Date may '. • -
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3Ik&e-C t\'edca\�
Printed Name of Signee �' •• •
MASON COUNTY PUBLIC HEALTH '_ '_ •.•0.
•�• %stq�eo2 � .
The undersigned approves this Installation Report and v 0:jAMES AI LF {
Record Drawing on behalf of Mason County Public d /`LIC b 0 IGNFR
Health:
\r -\(\Q-0\j )SIX\ ( zJL
Signature of Environmental Health Specialist Date (stamp, signature and date)
9 ( p 9
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE updated 8r212oie
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