HomeMy WebLinkAboutSWG2021-00508 - SWG As-Built - 1/12/2023 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG '.)L.)?., • Odsl)Q, Parcel # to).0,5 0 y
Applicant Name to-1001 N e- Subdivision (Name/Div/Block/Lot)
Applicant Address I.0 Osi4c I L(1 J 4cnoCity, State, Zip 5p0 W A Cf5�i Installer Name 14- fo
Site Address Vtvl4 tAwyd Designer Name 3l'A IGiJ
/ t
INSTALLAT 1V CHECKLIST
❑ Full System Installation f❑ Tank(s)Only Drainfield Only ElRepair 0 Other
System Type _544r(OW ri.cc,so . Pretreatment Type
>5 ft. from foundation? - - ❑ N/A YES ❑ NO
>50 ft. from wells? - •- ❑ ❑
• >50 ft. from surface water? - - ❑ ❑
HCleanout between building and tank? - - Vc ❑ 0
✓ Tank baffles present? - - IZI ❑ 0
F- 24"access risers over each compartment?- - 0 0 ❑
W Effluent filter Installed?- .- El/ ff 0
Septic tank size /i/A— gal Manufacturer "7 4-
9 D-box water level and speed levelers used? - - 'N/A ❑ YES 0 NO
oO Manifold/D-box accessible from surface?- - ❑ RI 0
co Check valves installed? - - 0 (,a 0
0
Transport Line Size t Schedule/Class „Cc l %U
Bedrooms Installed (check one) 2 0 3 ❑4 ❑ 5 ❑6 0 Commercial/Other
>10 ft. from foundation?- - ❑ N/A cES ❑ NO
>100 ft. from wells?- - ❑ Lzr ❑
W >100 ft. from surface water? - - 0 Idi 0
LL >10 ft. from potable water lines?- - ❑ Vi 0
Z > 5 ft. from property lines and easements?- - ❑ VI 0
> 30 ft. fro downgradient curtain/foundation drains? - - ❑ ❑ 0
ci
Drapfilld level and observation ports present - - 0 ❑ 0
,121 Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - 0 Al ❑
Pump tank setbacks consistant with septic tank?- - N/A ❑ YES 0 NO
• Pump tank size gal Manufacturer
< 24" access riser(s)and accessible from surface?- - 0 0
H Alarm or Control Panel Installed? - - 0 0
a ,_,/
2 Control Panel equipped with Timer/ETM/Counter- - td 0 0
n- Pump installed in ❑ Bucket or ❑ On Block or ❑ Other i—
a. Pump Make/Model Ai/ 4— 0 Floats or IDTransducer
0=. Tank draw down id A in/min Pump capacity /'' to gpm Squirt Height /iii1- ft
Pump on time fr f\- Pump off time A Daily flow set at i'-i0t gpd
Updated 8/21/2010
Ids
Mason County OSS Installation Report pg. 2 Parcel# 942'). I?'c I 1
/6 5b 2—
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - 0 YES 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 pormanont record and must be accurate and descriptive enough to relocate In the need of maintenance activities and futuro development. Typical Record
Drawings contain: Dralnfield&manifold orientation&layout,Sopticlpump lank location,North arrow,reserve dralnfield,existing and proposed buildings,location of walls,watarfnos.
wells,observation ports,cieanouts,and other maintonnnce access points. Incornplolo Record Drawings may create additional delays In final Installation approval and related permits.
0 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-
dance with the septic design stamped'APPROVED"by
County Public Health and that any deviations shown Mason County Public Health and that any deviations
4 here have been cleared/approved by both the designer shown here have been cleared/approved by both
and Mason C. my Public Health and meet all State myself and Mason County Public Health and meet all
and Mason ' ounty Codes. State and Mason County Codes
I further c: lily that all 'nfs n ation contal - .n this I further certify that all Information contained on this
form an• : had 'cc./•;►raw•r; accurate. form and attached Record Drawing IS accurate.
, AAJ ai
Sign Are of installer Date
Semivett---F
Printed Name of Signee P `�45 ,s
MASON COUNTY PUBLIC HEALTH `' 51000121 `s��,
o jIM HENRY 17
The undersigned approves this Installation Report and LICENSED DESIGNER
Record Drawing on behalf of Mason County Public EXPIRES: 08/11.'y
Health:
I \-2P-7)
Signature oEnvironmental He&hh Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 8/21/2018
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