HomeMy WebLinkAboutSWG2022-00231 - SWG As-Built - 6/24/2022 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 20LZ- 0GZ3 A Parcel# 3z 50?53 6 3 0+ 2,.
Applicant Name ebm,/ & 6 19e0ri t Subdivision (Name/Div/Block/Lot)
Applicant Address /6 36S 3 r kik 0
City, State, Zip 7,4arYL(/¢. k rl4- 9F W 5 Installer Name ay a/ PAS,
Site Address 3(6,) A) &AicE SueF L //i . signer Name /V - A-
INSTALLATION"CHECKLIST
0 Full System Installation E,Tank(s)Only ❑ Drainfield Only .Repair 0 Other
System Type u ie 4_13 i A= ' 7`.4rvr Pretreatment Type
>5 ft. from foundation? - - ❑ N/A gis,YES ❑ NO
>50 ft. from wells? - �--. _ _ ❑ J- 0
>50 ft. from surface water? - \1-T. aW - _ ❑ 0
Z --t -
a Cleanout between building and tank? - f _
U Tank baffles present? - ii1N 9, 4 , 0
a. 24"access risers over each compartmen , ---- - _ ❑El '... ❑
W Effluent filter installed?- El 0
� -- --
Septic tank size J2Z 7t' -
O 7gal Manufacturer A-G,e,e/ti/a-# ,oEk- JGIA/ " ' l'
a D-box water level and speed levelers used? - 0 N/A ❑ YES 0 NO
OLLO Manifold/D-box accessible from surface?- PU-_- 0 0 0
OZ Check valves installed? - _ ❑ ❑
a 0
2 Transport Line Size Schedule/Class
Bedrooms installed (check one) 0 2 0 3 ❑4 0 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- - ❑ N/A ❑ YES ❑ NO
G >100 ft. from wells?- 0 0 El
—J >100 ft. from surface water? - ❑ ❑
W
Z >10 ft. from potable water lines?- - - - - - CI ❑
Q > 5 ft. from property lines and ea en r---_ - - - - ID ID
W > 30 ft. from downgradient curtai fo atio ns? ❑ ❑ ❑
0
Drainfield level and observation resent -
0 Graveless chambe ID Clean gravel used? (check one) ❑ ❑ 0
Proper cover i ed over drainfield?- ❑ ❑ ❑
Pump tank setbacks consistant with septic tank?- - 0 N/A 0 YES 0 NO
Pump tank size gal Manufacturer
Z
< 24"access riser(s)and accessib frot surface? ❑ ❑
lZ Alarm or Control Panel Installed ❑ ❑
2 Control Panel equipped with Ti r M/Coun r- - - - ❑ ❑ ❑
a• Pump installed in ❑ Bucket or ock or ❑ Other
CL g Pump Make/Model ❑ Floats or ❑ Transducer
a,
a Tank draw dow in/min Pump capacity gpm Squirt Height ft
Pum ime Pump off time Daily flow set at gpd
Updated 821/2018
309 z_.
Mason County OSS Installation Report pg. 2 Parcel# )2-30(—�3-4
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - °YES NO
If yes, please describe: rv!'r/w oar- A k p!I F/ w11/&?,P,q.�
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 an-ow,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.
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-Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
I certify that l 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 ached cord Drawing is accurate. form and attached Record Drawing is accurate.
Sign I taller Date
P4i,,v f (7
Printed Name of Signee
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public
Health:
(� Z�
Signature of nvironmental Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE UpdaledBPltrzota
5-361 - 53 - D3o3e___
RECORD DRAWING (continued)
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I APPROVED
1 JUN 2F 2022
I MASON COUNTY ENVIRONMENTAL HEALTH 7
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