HomeMy WebLinkAboutSWG2022-00056 - SWG As-Built - 1/6/2023 CLEAR FORM
Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2022-00056 Parcel # 322147501300
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 30 NE Cady Ln, Belfair Designer Name Jim Zimny
INSTALLATION CHECKLIST
® Full System Installation 0 Tank(s)Only 0 Drainfield Only ❑Repair ❑Other
System Type Gravity Pretreatment Type
>5 ft. from foundation? - - 0 N/A ®YES ❑ NO
>50 ft. from wells? - . --*z - 0 ® 0
'T - r= 2h-iy-- - 0 ill El
ft. from surface water' �-e, -,
ct Cleanout between building and tank? 6.�� —;y ;�] a ❑
U Tank baffles present? N-(� - 4 a ❑
f- 24" access risers over each compartment?-- -w-�ALT-yLr ,,RQ I : °' ® 0
W Effluent filter installed?- Jaw Ahlj h/Eq a 0
N
Septic tank capacity (working) 1200 gal Manufacturer Hagerman
0 D-box water level and speed levelers used? - - ❑ N/A '® YES ❑ NO
DO Manifold/D-box accessible from surface?- - 0 ® 0
0?-2 Check valves installed? - - El 0 0
a Li <<
Transport Line Size Schedule/Class 3v 9
Bedrooms installed (check one) ❑ 2 0 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- - ❑ NIA ® YES ❑ NO
O >100 ft. from wells?- - 0 In El
W >100 ft. from surface water? - - 0 EN El
u. >10 ft. from potable water lines?- - 0 ® 0
Z > 5 ft. from property lines and easements?- - 0 BE 0
a > 30 ft. from downgradient curtain/foundation drains? - - ❑ 1W 0
CI
Drainfield level and observation ports present - - 0 IN 0
❑ Graveless chambers or 0 Clean gravel used? (check one)
Proper cover installed over drainfield?- - 0 ® 0
Pump tank setbacks consistent with septic tank?- - ❑ N/A ❑ YES ❑ NO
Y Pump tank capacity (flood) gal Manufacturer
< 24" access riser(s) and accessible from surface?- - 0 0 0
E-EL Alarm or Control Panel Installed? - - 0 0 ❑
2 Control Panel equipped with Timer/ ETM/Counter- - 0 0 0
D
a Pump installed in ❑ Bucket or 0 On Block or ❑ Other
n'• 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 8Y1;2018
Mason County OSS Installation Report pg. 2 Parcel# ZZ 4.--`7 5-0 / T 0 0
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - — - 0 YES g 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 permanent record and must be accurate and descriptive enough to re-locate in the need of maintenance artnnties and future development Typal Record
Ofirmngs Ccctainw Drad cieid.ma+itokl orreria4on.layout.Sepedpump lank locatwn.Rath arrmr,IL-Sea ie•drxt `d txi-41e.3 an c x,sed traitexteis.tocaten of wtCs.Waldo'O .
vrelts.obsenaben forts.cteara.tl.and Meer mainlec u ce arce a Rooms huanpiCte Retora Oraaings may create aOsLorel de+ays mina;vista'aten an:roval and rdeted pt rues.
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ON COUNT y ENVIRO f
JB w MENTAL HEALTH
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
1 further certify that all information contained on this i further certify that all information contained on this
form nd aft bed Record Drawing is accurate. form and attached Record Drawing is accurate.
Vii,k /6 t I .- t 0-ZL'_,.
Sig mre of installer Date
Printed Name of Signee
MASON COUNTY PUBLIC HEALTH '...‘
The undersigned approves this Installation Report and N� j V m,�
Record Drawing on behalf of Mason County Public . 012
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Heal
2./
tL / / ` / ` -3 uc t DESIGNER
Expiret BJLJ/Z
Sigre of Environmental Health Specialist Date (stamp.signature and dale)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SiTE UNat,d 8,2 i,2018
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