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Mison County OSS Installation Report pg. 1 MASON COUNTY • ,e-Lt gtlEALTW S
APPLICANT/ PERMIT INFORMATION e,, 6 20�;
Permit Number SWG Z — �6 Parcel# `4Zz76 S/o0 //Z
Applicant Name f��'afj/ VU (�r f2 Suubbdiivision (Name/Div/Block/Lot)
Applicant Address /66,i (DK>�/vrva eel-4 D(j//O LG 7L //Z �� /
Mk1 City, State, Zip f-/0OOS/4°Oe- ' S Installer Name .j ,44/tt/ ...: �.-IL, `/'0)1 /1-45 1
Site Address 0 i Designer Name A Di r"( t-I thhTr IZ-
INSTALLATION CHECKLIST
ull System Installation ❑Tank(s)Only ❑ Drainfield Only '.Repair ❑Other
ISystem Type /3 Jilorl Le 5 S 5 iD P,/>tX Pretreatment Type
>5 ft. from foundation? - - ❑ N/A igYES ❑ NO
>50 ft. from wells? - - ❑ El ❑
>50 ft. from surface water? - ❑ B ❑
o Z ,
HCleanout between building and tank? - - ❑ El ❑
U Tank baffles present? - - ❑ ❑
a24"access risers over each compartment?- - ❑ 14 ❑
N Effluent filter installed?- - 0 ❑
Septic tank size /060 gal Manufacturer „ZNFiiT~ zM /0G.0
9 D-box water level and speed levelers used? - - aN/A 0 YES ❑ NO
I
di
m Manifold/D-box accessible from surface?- - - ❑ ElZ Check valves installed? ❑ ❑
GQ+ ,.
a! Transport Line Size R Schedule/Class £a
Bedrooms installed (check one) -,2 1 4(!t k' l 6 ❑CommerciaVOther
>10 ft. from foundation?- -i - ❑ N/A YES ❑ NO
O >100 ft. from wells?- -m ttyL3 - ' ' - ❑ Er 0
W >100 ft. from surface water? - - ElCI
u. >10 ft. from potable water lines?- - ❑ ❑
Z >5 ft. from property lines and easements? By_____— —' ❑ 1 ❑d 3,5
>30 ft. from downgradient curtain/foundation drains? .
❑ El
in i
Drainfeld level and observation ports present - - ❑ IK ❑
Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ ❑
Pump tank setbacks consistant with septic tank?- - ❑ N/A TAXES ❑ NO
Z Pump tank size / Z(20 gal Manufacturer Jf/c.T!{i9j, Solio
I
O G
< ;24"access riser(s) and accessible from surface?- - ❑ z. ❑
0 'Alarm or Control Panel Installed? - - ❑ !l ❑
2 Control Panel equipped with Timer/ETM/Counter- - ❑ ❑
m
d Pump installed in %Bucket or ❑ On Block or ❑ Other
n' !Pump Make/Model AY-er S /tt.e 3 F $Floats or ❑ Transducer
a Tank draw down 2.1A- in/min Pump capacity 0 qpm Squirt Height J f3 ft
Pump on time M1R/ Pump off time /5 Daily flow set at gpd
Updated 8/21/2018
Mason County OSS Installation Report pg. 2 Parcel# JL2/b 5 / - Dt) 1 1 2--
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - I YES 0 NO
If yes, please describe: ( Y'c15 h-( I -act-toys-2- i 14 OK AP.re, et/liD/^x9
Were all components pumped out and property abandoned per WAC246-272A-0300? - - [ES El NO
RECORD DRAWING
I 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: Draartieid&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.
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
I further c- that all information contained on this i further certify that all information contained on this
form an, . . le.rd Drawing is accurate. form and attached Record Drawing is accurate.
IllD3 2 ,�
Signa i .f l stall r1)14-4 I 13 • n, Date U� 1-SJ�L
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Printed Name of Signee „W,,, •,r�, •:•<<;
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MASON COUNTY PUBLIC HEALTH s,
The undersigned approves this Installation Report and 1N.11J :
ADAVIJ.HUNTER
R Drawing on behalf of Mason County Public c• y'S:I.x4rik '
Health: �..�
t al�.N[; o,'itu
C9141 , /Z
Signature of Environme 7I Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 8/21/2018
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