HomeMy WebLinkAboutSWG2021-00235 - SWG As-Built - 6/21/2022 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2,021-0UW3 Parcel # ?j\G\('i 1.2- ('FORS
Applicant Name EIM,p1`R-f. lkornu CovnS a-k-cy 1\AS, Subdivision (Name/Div/Block/Lot) -,;247,,,
Applicant Address ob z.DX ?0\
City, State, Zip p Mbt MA G181D2v Installer Name \�
SSOt Pt 4:0/. ✓�> ,`\
Site Address 2\fl\SS N2sc£Y1k 94- Designer Name —("Z V\S ZllC - \
• -'`
INSTALLATION CHECKLIST
Full System Installation El Tank(s)Only ❑ Drainfield Only El Repair ❑Other
�" System Type_SLOOSu QC. DX2 Pretreatment Type BY Q._-' 1Y) cf
>5 ft. from foundation? - -- ❑ N/A FfYES ❑ NO
>50 ft. from wells? - -- - ❑ ❑
• >50 ft.from surface water? - -- ❑ Et ❑
Z
< Cleanout between building and tank? - - ❑ Q�,/
V Tank baffles present? El Lid ❑
a24" access risers over each compartment?- - El ❑
W Effluent filter installed?- ❑ �a ❑
N �° SaAn d acte�i 11
Septic tank capacity(working)Y1A�1\(a11,� 8n�"�I Manufacturer ��
5 D-box water level and speed levelers used? - - IYINIA ❑,(YES ❑ NO
oO Manifold/D-box accessible from surface?- - QA �S - ❑ u ❑
L.
mZ Check valves installed? - -- ❑ ❑
B 2 Transport Line Size_ t i 1n- Schedule/Class SCA40
�
Bedrooms installed (check one) ❑ 2 V3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- -- Q N/A ErYES El NO
® >100 ft.from wells? ❑
W >100 ft.from surface water? - - g 161 ❑
i„ >10 ft. from potable water lines?- - ❑ Q ❑
Z > 5 ft. from property lines and easements?- - ❑ I ❑
a2 >30 ft. from downgradient curtain/foundation drains? - -- - - - ❑ 2 ❑
Ci
Drainfield level and observation ports present - - - - ❑ u ❑
❑ Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- -- ❑ Ltd ❑
Pump tank setbacks consistent with septic tank? - - ❑ N/A YEs ❑ NO
Pump tank capacity(flood)/SW gal Manufacturer S.A.)/VD .V+c..Ef'1EAIT
Z 24" access riser(s) and accessible from surface?- - ❑ El ❑
Ia-
a Alarm or Control Panel Installed? ❑ i ❑
2 Control Panel equipped with Timer/ ETM /Counter- - ❑ EK ❑
m
13. Pump installed in ❑ Bucket or [ 'On Block or ❑ Other
CL Pump Make/Model tf---K -� .PF20o511 ❑ Floats or LI Transducer
a
Tank draw down I " _in/min Pump capacity kS gpm Squirt Height NIA- ft
Pump on time Co Vv\110 Pump off time t-1 ,V-hrtl&) Daily flow set at '3C'O gpd
Updated 8/21/2018
Mason County OSS Installation Report pg. 2 Parcel# 314i 0i SS CJUo 9S
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - ❑ YESnl 1 a �NO
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - ❑ YES ,.)1,14 ❑ 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.
❑ 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 ' ormation contained on this 1 further certify that all information contained on this
ffor .and attach d eco d g is accurate. form and attached Record Drawing is accurate.J-i�
� " (. 22
S na ure of lnstalle Date
t�-�Six S- i-lrz-T�
Printed Name of Signee m • ?�.
MASON COUNTY PUBLIC HEALTH , `� '-.F
-l6-12Z
The undersigned approves this Installation Report and a/ 5100384 '
Record Drawing on behalf of Mason County Public 01 TRAVIS C.BUCKT
LICENSED DESIGNER
Health: ``'7
Ex P:aES 11-17-20
(6i/5.,knossliii L(z_7/7,,z.
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 8121/2018
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