HomeMy WebLinkAboutSWG2020-00323 - SWG As-Built - 8/22/2022 a
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OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT!PERMIT I FORMATION -
2p— CO323 Parcel# ' Z ? �7 t-CO '-\Z
Permit Number SNKi(9,4"
¢ Subdivision(Name/Div/Block/Lot) '-
Applicant Name
Applicant Address� _1 C g' M-- i
City,State,Zip
h! 4 ,`v`-i Installer Name P�1\I e Lit -
•
tr y-t.S. c. signer Name ( `'
Site Address ;i-0,.
INSTALLATION.CHECKLIST
Drainfleld Only 0 Repair ❑Other •
•.a
`Q Full System Instanation 0 Tank( Only ❑ `.ti
System Type �)t W 1�p`t� Pretreatment Type (�_
>5 ft from,foundation? - 0 NIA YES ❑❑NO i.
>50 ft.from weds? ❑ C.,;
_ >50 ft from surface water?- ❑ )
�a] ❑ � '
< Cleanout between budding and tank? - ❑ "� p J'
I- 0 �i] ❑
U Tank baffles present?-
d24'access rises over each compartment?- ❑ �.I ❑
ItI Effluent fitter installed?- ID taO--+-' -- �J 0 0 _
Septic tank -BNB 1 gal Manufacturer t.W. "Cu- 1
D-box water level and speed levelers used? • . 0 NIA 0 YES 0 NO ( :„
oO ManifoldlD-box accessible from surface?- - ❑ ❑ 0
cl? Check valves installed?- - ❑ 0 0
OQ
E Transport Line Size Schedule/Class
Bedrooms installed(check one) 0 2']3 ❑4 0 6 ❑6 ❑Commercial/Other
>10 ft from foundation?- 0 NIA YES ❑❑ NO �`
0 >100 ft.from wells?- - 0 \...e
-I >100 h.from surface water?• 0 ❑
W :.
cr. >10 fr from pptable water lines? ❑ 0
� �'
Q %5 ft.from property lines and easements?• . 0
re >30 ft from downgradient curtain/foundation drains?- - 0 '''&1 CI —( r
`
Drainfiekd level and observation ports present- _ 0
''El El '' 4
�] Graveless chambers or ❑ Clean gravel used? (check one) El - -s
Proper cover installed over drainfield?- -
0 NEI 0 r
Pump tank setbacks consistent with septic tank?- -
❑ NJA ] YES ❑ NO .Z Pump tank size (2_Q D gal Manufacturer S•Dvt4 d 'PktL Y�
Q 24'access riser(s)and accessible from surface?- �F- Alarm or Control Panel Installed?- ❑ ❑
ja ❑
Control Panel equipped with Tuner/ETM/Counter- - ❑
a Pump installed in 0 Bucket --O.---'Er
❑ ❑
CJ On Block or ❑ Other
Pump Make/MOdeI S p�\ \� 2 R 1 =
Tank draw down " Floats or ❑Transducer
n �_In/min Pump ca acit
Pump on time ( P y�' Pm Squirt Height 14v
Pump off time firs S ft
Daily flow set at
Pd.
0
:;-; fir
i r 5'
. "'M'F i
ate. ' -
a ,- R ' , ..
a
: "oss Installation Report pg. 2 Parcel# a`.
le 3-
i`� -I ty ABANDONMENT RECORD
S a .. WK...
aePt'o components abandoned as pan of this prefect? 0 YES (i) NO
°1 gdescribe f'
r°f're nts pumped out and properly abandoned per WAC248-272A-0300?- - ❑YES 0 NO
RECORD DRAWING }'
neatperm.nanneatd and must b.accursss sad aaalp a ly+engh N M to radasWt the el MaMlaNa s arid salviad lulu,d■e4opmsnt Typical Read
�t"y
Dr■ndfelr&manifold orttdalion a Mpord.SapOdpernp ant loNson.Negri WOK Marva draYtlUN,exiting and proposed brdNeps.McsW ofonreels.wrote**.
xi*c,..,t■.co1.1.orvsoon Gas'desnouts.end oilier naMdsna c*access point. MrownMMM p000rd Ontralnat rear orals additional delays Is Mel last lrllon approval and rWeed permit
i
I-
❑ Record Drawing Attached
CERTIFICATION OF INSTALLATION
iIp0i
INSTALLER DESIGNER'ENGINEER
I certify that I installed the system in accordance with I certify that the system has bean installed in actor-
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 Courtly Codes
I further codify that all information contained on this I further certify that all information contained on this 111'
forma ord D wing is accurate. font and attached Record Drawing is accurate.
1
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Signature of Installer Dale `t.
fl Ur�
Printed Name of SI nee Ji .
41
MASON COUNTY PUBLIC HEALTH ,1•• I
The undersigned approves this Installation Report and • s
CV
l }
•
Record Drawing on behalf of Mason County Public -,' Boci:'J. r •r '*
He /th Ti
.tom e Lr n_
�/ZZ--i2 �
Signature of Errvironrnental ealfh Specialist Date (stamp,signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBUC VIEW ON THE MASON COUIITY WEB SITE updstod er21/Ni16
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