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HomeMy WebLinkAboutSWG2020-00670 - SWG As-Built - 8/8/2022 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG 2020-00670 Parcel# 42307-50- 00049 Applicant Name Ron Kruger Subdivision (Name/Div/Block/Lot) Applicant Address 15689 Yokeko Dr. Lake Cushman Div. 2 Lot 49 City, State, Zip Anacortes, WA 98221 Installer Name T.J. Goos Site Address 10 N. Potlach Dr. N. Designer Name Dale L. Tahja INSTALLATION CHECKLIST El Full System Installation El Tank(s)Only ® Drainfield Only ❑ Repair 0 Other System Type Pressurized Trenches Pretreatment Type N/A >5 ft. from foundation? - - ❑ N/A ❑YES ❑ NO >50 ft. from wells? - - ❑ El 0 Z >50 ft. from surface water? - El Ila Cleanout between building and tank? -- T�- li - 0 El El U Tank baffles present? - 1 -zr-2-5 n 7, El ❑ 17- 24" access risers over each compartmen ia. ✓-}- El ❑ I Effluent filter installed?- By=- ii- ❑ ❑ ❑ Septic tank capacity (working) _ gar----Maitufacturer 9 D-box water level and speed levelers used? - - • N/A ❑ YES 0 NO 00 Manifold/D-box accessible from surface?- - ® El ID mZ Check valves installed? - - ® El ❑ thQ 2 Transport Line Size Schedule/Class Bedrooms installed (check one) 0 2 ❑ 3 ❑4 0 5 El 6 El Commercial/Other >10 ft. from foundation?- - ❑ N/A ® YES ❑ NO O >100 ft. from wells?- - 0 It 0 W >100 ft. from surface water? - - 0 ❑ II ti >10 ft. from potable water lines?- - ❑ © ❑ > 5 ft. from property lines and easements?- - 0 NI d > 30 ft. from downgradient curtain/foundation drains? - - ❑ ® ❑ • Drainfield level and observation ports present - - ❑ IN ❑ 0 Graveless chambers or ❑ Clean gravel used? (check one) Proper cover installed over drainfield?- - ❑ II ❑ Pump tank setbacks consistent with septic tank?- - ❑ N/A ❑ YES ❑ NO • Pump tank capacity (flood) gal Manufacturer < 24" access riser(s) and accessible from surface?- - ❑ 0 ❑ a. Alarm or Control Panel Installed? - - ❑ ❑ ❑ 2 Control Panel equipped with Timer/ETM/Counter- - ❑ 0 ❑ M d Pump installed in ❑ Bucket or ❑ On Block or ❑ Other d• Pump Make/Model ❑ Floats or 0 Transducer a. a Tank draw down in/min Pump capacity (pm Squirt Height ft - Pump on time Pump off time Daily flow set at gpd Updated 9/21/2018 r 1. Mason County OSS installation Report Pg. 2 Parcel# 3() _5TT•6Lil ABANDONMENT RECORD Were existing septic components abandoned as part of this project? - - 0 YES i NO If yes, please describe: Were all components pumped out and properly abandoned per WAC248-272A-0300? - - 0 YES 0 NO RECORD DRAWING . This la a permanent record and must be accurate and descriptive enough to re-locate In the need of maintenance activities and future development 1Vpicrd Record Draw>rgs contain: Drnintleld d manifold orientation 3 Ieyout,Septic/pump tank location,North arrow,reserve draWReid,exMng and proposed btIc nds.Wean of web,waterlines, wade,observeldon pate,deanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays In Mal Installation approval and related permits. • 4 IIIRecord Drawing Attached CERTIFICATION OF INSTALLATION INSTALLER DESIGNER!ENGINEER I certify that l installed the system in accordance with 1 certify that the system has been installed in accor- the septic design stamped"APPROVED"by Mason dance with the septic design stamped"APPROVED"by i 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 hem 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. Slate and Mason County Codes I further certify that all information contained on this I further certify that all information contained on this form and attached Record Drawing is form and attached Record Drawing is accurate. ,. - .7-1 Ze____e_r_ .. Ai 0,4 Signature or l Date ,=•i��et- • '•• Printed Name of Signee f A °tct c* • 1 MASON COUNTY PUBLIC HEALTH f �k,�, s'+at The undersigned approves this installation Report and V"' 5100214 `r�` Record Drawing on behalf of Mason County Public ar0 '� DALE L.TAH JA '.7 t UUCENSEO DESIGNER >Z Health: %f c. 1 EXI:?$':. - -.... _ 2 Signature of EnvIrunilienta1 Health Specialist Date (stamp, signature and date) THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE UPtlai'd 82112o1e fli .• ,-.... ,. ., (I''''•••• .• / • '-- . 1 I *---,...,, 1 ) , • • I iy11.41 ••• ••• ...'•:?%')....-IY3 ". teroioorith..1104.1b..111k •'5.,:';:...;*;:S 4..:7.5:1 •4 •3ND1S?.:.:CI:••rt:::....i1.1 • • • - - - - • • - - - - /--7; St •' w VI 1 31Va . •--, timis WA ....• 1 iv I r A In' ..f ,At • 'A ,4*•,;-,4'. ,,,,.........,v • ...,-..... er .... ,i4, 00 .A• k4llth•w A. ke Ler ••• OP 0 at-- • /7I 11: . \ • . ! fr ' / .01 • . : / tt9' • a) ; •••0\ ) i co • i cjj-- •...• .. %, .. 0, ). • — -- .1 ...•e. - if i • /%....,.......,..N%.... . . -----' -"- ---------' 4*---- ., •Z , -..../ ,i7, 0 I. k el, r •x t'. .-5.: i • /,... .Or .:,. t,r :!.,. ir 4-... 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