HomeMy WebLinkAboutSWG2022-00055 - SWG As-Built - 1/6/2023 Emma
-Masai County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2022-00055 Parcel # 322147501200
Applicant Name David Cooper Subdivision (Name/Div/Block/Lot)
Applicant Address 4826Se Sleepy Hollow Ct
City. State. Zip Port Orchard Wa 98366 Installer Name JACK JOHNSON
Site Address 3 1 NE Cady Ln, Belfair Designer Name Jim Zimny
INSTALLATION CHECKLIST
® Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑Repair ❑Other
System Type Gravity Pretreatment Type
>5 ft. from foundation? - - 0 N/A III YES ❑ NO
>50 It. from wells? - - 0 IN
Y• >50 ft. from surface water? -s�-� - ❑
Q Cleanout between building and tank? - --- - ;. U 0
I- 6_2D13__ ■ 0
U Tank baffles present? IVCOUAr 4 �2
E
a24"access risers over each compartment?- �VJRpM "lrHEAL_ ❑ U 0
W Effluent filter installed?- s-l14 - L.1 ® ❑
to
Septic tank capacity (working) 1200 gal Manufacturer Hagerman
0 D-box water level and speed levelers used? - - 0 N/A ® YES ❑ NO
XO Manifold/D-box accessible from surface?- - 0 El
mz Check valves installed? - - a ❑ 0
0<
Transport Line Size i' Schedule/Class ,2,6 44
Bedrooms installed (check one) 0 2 ■❑3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft.from foundation?- - ❑ N/A ® YES ❑ NO
O >100 ft. from wells?- - 0 ® 0
W >100 ft. from surface water? - - 0 NI
u. >10 ft. from potable water lines?- - 0 If 0
Z > 5 ft. from property lines and easements?- - 0 4 0
CD
> 30 ft. from downgradient curtain/foundation drains? -
❑ HI El
level and observation ports present - - ❑ 4 ❑
❑ Graveless chambers or 4 Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ ® ❑
Pump tank setbacks consistent with septic tank?- - ❑ N/A ❑ YES ❑ NO
`-t Pump tank capacity (flood) gal Manufacturer
< 24" access riser(s)and accessible from surface?- - 0 0 0
tl Alarm or Control Panel Installed? - 0 0
n Control Panel equipped with Timer/ ETM /Counter- - 0 0 ❑
D
a- Pump installed in ❑ Bucket or 0 On Block or 0 Other__
a.• Pump Make/Model 0 Floats or 0 Transducer
d
Tank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
Updated 8/2112018
Mason County OSS installation Report pg. 2 Parcel# 3 Z 2- 14"� 7S o i _0 0
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - ❑ YES 4. NO
if yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300?- - 0 YES ❑ NO
RECORD DRAWING
This is a pernranmt roco d and must be accurate and doscriptire enough to re-locate in the need of maintenance activities and future development. Typecal Record
Oray.in js cenlan: Ornintield b masridd otiendaton&taymt,Sepleourr'p tank kgoion,41,4114t ono v,reserve dramrle'd,existing and proposed buftrigs,locaton of wets.traledates,
weus.obeer/alen Forts.neanot:is.and other mau tera ce access palms iru mptele Reccad Ora-urn:3i may create aCcatoral(Ways in final ers& U to .l
a approval and rotated petnc
APPROVE
JAN66203
MASON COUNTY ENVIRONMENTAL HtilEALTH
JBW
®.,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
forfrt nd all yhed Record Drawing is accurate. form and attached Record Drawing is accurate.
Sig(91-'t/tA
re installer Date
1JGr .Jv 'l✓1j7a-1n
Printed Name of Signee
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Publicct w' T,
wry
t to L :.rt; OEs!GNER
t-k) t\-44N, 4_z3 ExpiroG.srtrr
Sign to nvironmental Health Specialist Date (stamp.signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SiTE Uldale1H21 2018
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