HomeMy WebLinkAboutSWG2021-00236 - SWG As-Built - 6/21/2022 c.,,,,.....),
Mason County OSS Installation Report pg. 1 /MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
. Permit Number SWG LQ2.1 - 0023(p Parcel #3\q CA Gj5 ()coC 2
Applicant Name tN1(l R .160A.2 Ds\S ruC>h q Subdivision (Name/Div/Block/Lot)
Applicant Address V() ?)6( 1 1-= ✓G •
4b
�!� �g�2� Installer Name VCSSCA kr\)
`, City, State, Zip �/Q,��Cj� �'
Site Address St C.�MCAA:6 VQ. Designer Name �YG\(\S bu- ti c?
D
INSTALLATION CHECKLIST •
a
Full System Installationio El Tank(s)Only ElDrainfield Only El Repair ❑Other
V(System Type W SW( D' Pretreatment Type k %jQl X- -,11112- ._
>5 ft. from foundation? - -- ❑ N/A BYES ❑ NO
>50 ft. from wells? - - d ❑
Z >50 ft.from surface water? - -- g 12/ ❑
HCleanout between building and tank? - - ❑ g ❑
U Tank baffles present? - - ❑ Eir ❑
a24"access risers over each compartment?- - ❑ �g. CI
W Effluent filter installed?- - ❑ [. ❑
N ,,�D
Septic tank capacity(working)\U\/\(ck V.. 11►VgiP0 Manufacturer SIAAnd AA Ce.)WtoY
5 0-box water level and speed levelers used? d - �N/A El YES El NO
OO Manifold/D-box accessible from surface?- - - V9 - - - - ❑ Q' ❑
mZ Check valves installed? - -- [vr ❑ ❑
GQ .
2 Transport Line Size I 1Y\.() Schedule/Class 3C,cLID
Bedrooms installed (check one) ❑ 2 I3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft.from foundation?- -- ❑ N/A d YES ❑ NO
0 >100 ft.from wells?- - g Q ❑
W >100 ft.from surface water? - - [S 1E( ❑
LT >10 ft. from potable water lines?- - ❑ 2/ ❑
Z > 5 ft. from property lines and easements?- - ❑ Di ❑
do
>30 ft. from downgradient curtain/foundation drains? - - ❑ [v' CI
Drainfield level and observation ports present - - ❑ d ❑
❑ Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield? - ❑ ❑
Pump tank setbacks consistent with septic tank? - - ❑ N/AS ❑ NO
• Pump tank capacity(flood)/5-00 gal Manufacturer c(,A3b 1 A E11 E JT
< 24" access riser(s)and accessible from surface?- ❑ ❑
~ ❑ PK ❑
CI. Alarm or Control Panel Installed? - - - - -- -
E Control Panel equipped with Timer/ETM /Counter- - ❑ Cv-- ❑
M
Q- Pump installed in ❑ Bucket or ErOn Block or ❑ Other__
-
d• Pump Make/Model OP€NC() PFZt sit /oats or ❑ Transducer
=. Tank draw down r
O in/min Pump capacity , gpm Squirt Height t.JlAA ft
Pump on time tett+I` \L Pump off time \41,, s'irtt\V\ Daily flow set at 3 (At gpd
Updated 8/21/2018
Parcel# \k 5 0 0 6 c 2
Mason County OSS Installation Report pg. 2
i ABANDONMENT RECORD
i
Were existing septic components abandoned as part of this project? - - ❑ YES 1 yk VO
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - 0 YES,j/A} ❑ NO
RECORD DRAWING
t
l 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
9 Drawings contain: Drainfield&manifold orientation&layout,Septiclpump tank location,North arrow,reserve drainfield,existing and proposed buildings,location of wells,waterlines,
wells,observation ports,deanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays in final installation approval and related permits.
❑ Record Drawing Attached
I CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER!ENGINEER
1 certify that I installed the system in accordance with I certify that the system has been installed in accor-
fhe 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 attache Record Drawing is accurate. form and attached Record Drawing is accurate.
T/7'7 Z
igna re of n taller Date
--jAaSSKI J- c-7-
Printed Name of Signee
MASON COUNTY PUBLIC HEALTH 2, .�_„c _
` The undersigned approves this Installation Report and :: j :, %-��
�: stoo�ea ;m�
Record Drawing on behalf of Mason County Public ,o; TnAvts c Duc
LIC F.N5ED DES�NER
Health: 1
E%o!kES 11-L 2
I l C� - fzs7( l.
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 Updated 8/21/2018
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S�G\e ,n 0' 20' 40'
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2g
NuWater BNR 500
1500 Gallon .� Treatment Tank
`, Trash/Dose R��
Tank '�� ,iv�,-
'0 APPROVED
•
C' Headworks
c JUN 2 7 2022
MA,ON COUNTY ENVIRONMENTAL HEALTH
Proposed Water * RET
& Utility Lines cJ\\e "'o
` \ee o6,
_1 r• V\
cp.
Reserve Area / (2)Air/Vacuum
46' x 20' \ / Relief Valves
/ (See note 5)
Act-'); ''' -'%ik -tatZ 0 Z \
...• '1-- '.!P-- Z A
•O; TRAVf$C.BUCK \\v/-
LICENSED OES`CNER
eXA'AES 11-17-20
\ V
Please Note: This as-built has been drawn s�
for reference in assisting in locating the / Drainage Easement
septic area and is in no way intended to be
a survey. Utility lines and water line O
locations are estimated. This drawing is not Drip Field, 4
to be used to locate water or utility lines. Lines Total
(4 runs @ 45' V
per line)
Installed By: Dodge Excavation 720' total length
Permit Number: SWG2021-00236
Empire Home Construction LLC Advanced Septic Consulting Inc. Design: Date:
Parcel Number: 31904-55-00092 220 Hanson Rd. Kalama, Washington 98625 21-103 3/11/2022
Shelton, Washington 98584 Cell:360-433-5476 E-Mail travis@kalama.com As-Built Scale: 1" = 20'