HomeMy WebLinkAboutSWG2021-00238 - SWG As-Built - 1/6/2023i i
Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 762_1 -- 002_13$ Parcel # LiZ O35 — 114 — C00g()
Applicant Name Dy\�k._ L-� -�r Subdivision (Name/Div/Block/Lot)
Applicant Address go to..10-ccs -Te
City, State, Zip Si.e1\- \ li.3.4, g$5t"( Installer Name 065,kkte... Wiat-3{6,,wci t.C..
Site Address Ke aS ,A> J� Designer Name \ dca\c
INSTALLATION CHECKLIST
XFull System Installation❑Tank(s) Only ❑ Drainfield Only ❑ Repair ❑Other
System Type Installation,.
Pretreatment Type
>5 ft. from foundation? - - ❑ N/A MYES ❑ NO
>50 ft. from wells? - - ❑ I ❑
Z >50 ft. from surface water? - �} -{ {7ij 5 �' ❑
• Cleanout between building and tank? - - - _ _ V� ■ X ❑
U Tank baffles present? - 'r - 444 V-a-Z023 - ❑ gi ❑
d24" access risers over each compartment?- ❑ rg CI
W Effluent filter installed?- i3y- - - - - ;1_1, tgi ❑
cn ``
Septic tank capacity (working) / , gal Manu - • -
I
rn D-box water level and speed levelers used? - - tg N/A ❑ YES ❑ NO
oOJ Manifold/D-box accessible from surface?- - GICI
co-2 Check valves installed? - - ❑ Cif ❑
0 Q /t H 2 Transport Line Size � c,�i Schedul9s
Bedrooms installed (check one) ❑ 2 X3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- - N/A M.YES ❑ NO
CD >100 ft. from wells? A.P .PR V E 1 CIW >100 ft. from surface water? - ❑
LI >10 ft. from potable water lines?- - - JAN-Q 6 17123 X re
• _, ❑
Z > 5 ft. from property lines and easements?- ❑
MASON COUNTY ENVlR ?ENTAL HEALTHE
Q 30 ft. from downgradient curtain/foundation drains?- J� �Cill CI
Drainfield level and observation ports present - t2 ❑
'g Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ X ❑
Pump tank setbacks consistent with septic tank? - - ❑ N/A RYES El NO
• Pump tank capacity (flood) k100 gal Manufacturer -;
< 24" access riser(s) and accessible from surface?- - ❑ ❑
I—
a. Alarm or Control Panel Installed? - - ❑ ❑
2 Control Panel equipped with Timer/ ETM /Counter- - ❑ t ` 1 1 CI
a Pump installed in ❑ Bucket or El On Block or X'Other ?� �'`t1 �+)( l t ks"tg
a.E Pump Make/Model V_.; 3 �t 2 KFloats or ❑ Transducer
Tank draw down Z, in/min Pump capacity -5 7 gpm Squirt Height 5 ft
Pump on time / /K/41 Pump off time ? ALA./ Daily flow set at 31-1Z.- gpd
Updated 8/21/7018
Mason County OSS Installation Report pg. 2 Parcel# L/ZO35 ( 4._ QOOVO
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - YES NO
If yes, please describe:
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 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.
APPROVE
JAN 0 6 2623
MASON COUNTY ENVIRONMENTAL HEALTH
JBW
gRecord 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-actin tion conta. this I further certify that all information contained on this
form aid attached or rn ' ccurate. form and attached Record Drawing is accurate.
/ZNZ �ryZ l 1,
ature of Installer Date .•
Jos ‘Me..A.C.Me
Printed Name of Signee �%
MASON COUNTY PUBLIC HEALTH r'/
The undersigned approves this Installation Report and ,!• ! ALF
.•� -0,•1� I NM.. d.
Record Drawing on behalf of Mason County Public i •MVA�•����•��������
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Health: �-
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Sig to 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 8/21rz01e
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