HomeMy WebLinkAboutSWG2021-00506 - SWG As-Built - 1/12/2023 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2Dd- ( • DO SD(0 Parcel # 104.I: ,S-/ /O S- h-
Applicant Name Pcy,AMA 14--14p, Subdivision (Name/Div/Block/Lot)
Applicant Address P, 0 Goy, 0-/OC/
City, State, Zip 011vt4pc gtS-vy Installer Name 4 ` 4M\r -
Site Address Vrvk Wwtn .Tr "-
l Designer Name /.1-�'�?�
INSTALLATIOIS-CHECKLIST
o ❑ Full System Installation CI Tank(s)Only rainfield Only ❑ Repair 0 Other
System Type $ "4/(0u- rizilti -C Pretreatment Type
>5 ft. from foundation? - - 0 N/A gj YES ❑ NO
>50 ft. from wells? - •- 0 Er 0
Z >50 ft. from surface water? - - 0 Z 0
HCleanout between building and tank? - - i2r. 0 0
V Tank baffles present? - - ❑' 0 ❑
a24"access risers over each compartment?- - ❑ 0
W Effluent filter installed?- •- 0 0 0
Septic tank size gal Manufacturer
5 D-box water level and speed levelers used? - - r2 N/A ❑❑I El
❑ NO
QOManifold/D-box accessible from surface?- • 0 .
?"" Check valves installed? - - El ❑
�R Transport Line Size D-t 1 Schedule/Class 5G Ii y o
Bedrooms Installed (check one) 2 ❑3 0 4 ❑ 5 0 6 ❑CommerciaUOt er
>10 ft,from foundation?- - ❑i N/A ES 0 No
>100 ft. from wells?- - 0 ❑
W El>100 ft. from surface water? - - 0
Z >10 ft. from potable water lines?- - 0 0
> 5 ft.from property lines and easements?• • D ❑
t2 > 30 ft.from downgradient curtain/foundation drains? - - 0 0
Drainfield level and observation ports present - • 0 0
r Graveless chambers or ❑ Clean gravel used? (check one)
•ro•-r cover installed over drainfield?- - ❑ (----
Pump tank setbacks consistent with septic tank?- • NIA 0 YES 0 NO
ZPump tank size gal Manufacturer
< 24" access risers)and accessible from surface?- - 1:e 0 El
H
a Alarm or Control Panel Installed? - - ❑ El
n Control Panel equipped with Timer/ETM/Counter- ` 0 0
L. Pump installed in El Bucket or 0 On Block or ❑ Other /v/ /)-----
--
a. Pump Make/Model A i ❑ Floats or 0 Transducer
Tank draw down N/ nirnin Pump capacity gpm Squirt Height /JJ/ ft
a '(
Pump on time Pump off time Daily flow set at gpd
Up1ale i 8,21t2018
Mason County OSS Installation Report pg. 2 Parcel if �(d-d--I )--- SDI /o S1 e-
ABANDONMENT RECORD
Wore existing septic components abandoned as part of this project? 0 YES C21N9
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - 0 YES No
RECORD DRAWING
Tills 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,Sepliclpump lank location,North arrow,reserve drainfieid,existing and proposed buildings,location of wells,waterlines,
wells,observation ports,cteanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays In final Installation approval and related pormIts.
II
0 Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
1 certify that I Installed the system In accordance with I certify that the system has been Installed In accor-
(he 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 Maso ounty Public Health and meet all State myself and Mason County Public Health and meet all
and Mas County Cod . State and Mason County Codes
I further ertify that all it rmltlon co alned on this I further certify that all information contained on this
form at d !tech is accurate. form and attached Record Drawing is accurate,
Sig, ure Installer Date
•
Printed Name of Signee .4- 4
1 3. t - iZ-Z3
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and 51000121
Record Drawingon behalf of Mason CountyPublic o, -HENRY_
LICENNSSED DESIGNER
Health, rxplat s es/1>i .7_'1
l' i \71-1'3
Signature of Environrnen al Health Specialist Date (statnp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated8,2112010
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