HomeMy WebLinkAboutSWG2022-00368 - SWG As-Built - 6/7/2022 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT! PERMIT INFORMATION
Permit Number SWG 2022-003(pg Parcel # 2240(0- 23-0 Jl2 j
Applicant Name ace/1K .fatn'IGI wes1&4 Subdivision (Name/Div/Block/Lot)
Applicant Address '20 N•Tr TtOb Head Pr- - 2 Of eiOVt. jot 2 +-MIDI.
City, State, Zip (,IIIMJ6I11p, Wt.\ cig6cos Installer Name woes E)(caw-609(S' rne)
Site Address 2.0 N Tt(1tDn tiefld Of- Designer Name
INSTALLATION CHECKLIST
❑ Full System Installation RiTank(s)Only 0 Drainfield Only ❑ Repair ❑Other
System Type standard PrActotre, Pretreatment Type
>5 ft.from foundation? - - ❑ N/A [d YES ❑ NO
>50 ft. from wells? - -- ❑ Ef 0
Z >50 ft.from surface water? - - ❑ Eir ❑
HCleanout between building and tank? - - ❑ 4 ❑
U Tank baffles present? - - ❑ El 0
I— 24"access risers over each compartment?- - 0 D 0
a.
1 Effluent filter installed?- .- [2] ri El
Septic tank capacity (working) I eta gal Manufacturer 12.0"f"h
`5 D-box water level and speed levelers used? - - 4 N/A 0 YES 0 NO
�O Manifold/D-box accessible from surface?- - 0 0
u.
QQCheck valves installed? - - 14 0 0
2 Transport Line Size Schedule/Class
Bedrooms installed (check one) d2 ❑3 ❑4 0 5 ❑6 ❑Commercial/Other
>10 ft.from foundation? - - ❑ N/A 0 YES ❑ NO
O >100 ft.from wells?- 1- 1 �-� f� 1 ❑ 0 0
W >100 ft.from surface water? - 11 - ❑ 0
0
IT >10 ft.from potable water lines?- - - - - - -1la!- .J-7 1 - ❑ 0 0
> 5 ft. from property lines and easements - ❑ ❑ ❑
W > 30 ft.from downgradient curtain/founda A drains?`-61" - ❑ 0 0
Drainfield level and observation ports preetil - - 0 0 0
0 Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ ❑ ❑
Pump tank setbacks consistent with septic tank? - - ❑ N/A 0 YES ❑ NO
• Pump tank capacity(flood) gal Manufacturer
Q 24" access riser(s)and accessible from surface?- - ❑ 0 0
~ Alarm or Control Panel Installed? - - ❑ ❑ 0
a
E Control Panel equipped with Timer/ETM /Counter- - ❑ 0 ❑
M
a. Pump installed in ❑ Bucket or 0 On Block or 0 Other
d• Pump Make/Model 0 Floats or 0 Transducer
a Tank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
Updated 8/21/2018
Mason County OSS Installation Report pg. 2 Parcel# 1291019 25-(XDO1JD
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - ,d YES NO
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - d 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.
El 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.
1)SI22
Signature of Installer Date
Shane Maples
Printed Name of Signee
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public
Health:
9ANOYI\PC611/1 1 17;C---
Signature of Environmentai Health Specialist Date (stamp,( p, and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 8/21/2018
RECORD DRAWING (continued)
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APPROVED
JUL 0 / 2022
MASON COUNTY ENVIRONMENTAL HEALTH
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