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HomeMy WebLinkAboutSWG2021-00628 - SWG As-Built - 7/18/2022 (2)'"'r'• ....... 1 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG SWG2021-00628 Parcel # 319141290100 Applicant Name PETROVICH MATTHEW &AM Subdivision (Name/Div/Block/Lot) Applicant Address 801 SE Dahman Rd City, State, Zip Shelton, WA 98584 Installer Name Scott Johnson Site Address Same as mailing Designer Name Micah Halverson INSTALLATION CHECKLIST it Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑ Repair ❑ Other System Type Gravity Pretreatment Type >5 ft. from foundation? - - ❑ N/A ® YES ❑ NO >50 ft. from wells? - - El II El Z >50 ft. from surface water? - - ❑ MI FQ- -if Cleanout between building and tank? - - ( - rd -fly- -- ❑ IN ❑ U Tank baffles present? - lJ LI - El © Eld 24" access risers over each compartment? - 4kJN-3-0 202.2- - ❑ I ❑ W Effluent filter installed?-co - - - El ® El Septic tank capacity (working) 15CMy pi Manufacturer Hagerman 0 D-box water level and speed levelers used? - - ❑ N/A 0 YES ❑ NO 01::) J Manifold/D-box accessible from surface?- - El ® El 002 Check valves installed? - - ® El El ciQ 2 Transport Line Size 4 Schedule/Class 3034 Bedrooms installed (check one) El 2 ❑ 3 ❑■ 4 El 5 ❑6 ❑Commercial/Other >10 ft. from foundation? - - ❑ N/A ® YES ❑ NO >100 ft. from wells?- - El II El W >100 ft. from surface water? - - El MI El u. >10 ft. from potable water lines?- - ❑ I El Z > 5 ft. from property lines and easements?- - ❑ ME ❑ Q w > 30 ft. from downgradient curtain/foundation drains? - - 0 El ❑ tn Drainfield level and observation ports present - - El PI El ❑ Graveless chambers or 0 Clean gravel used? (check one) Proper cover installed over drainfield?- - El I El 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?- - El El El H a Alarm or Control Panel Installed? - - El El El 2 Control Panel equipped with Timer/ ETM /Counter- - El El El m - Pump installed in ❑ Bucket or ❑ On Block or ❑ Other O.• Pump Make/Model ❑ Floats or ❑ Transducer a Tank draw down in/min Pump capacity gpm Squirt Height ft Pump on time Pump off time Daily flow set at gpd Updated 8'21,2018 Mason County OSS Installation Report pg. 2 Parcel# 319141290100 ABANDONMENT RECORD Were existing septic components abandoned as part of this project? - - ❑ YES Li NO If yes, please describe: Were all components pumped out and properly abandoned per WAC246-272A-0300? - - ❑ YES ❑■ NO RECORD DRAWING 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: Drainfield&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. Ak_\c,,c),_.CL 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- 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 certify that all informa ' n contained on this I further certify that all information contained on this form nd attached Rea rawing is accurate. form and attached Record Drawing is accurate. -----"r„,...---- Signature of I alter Date S0 ),‘OSP1 LCL ./- Printed Name of Signee ,� MASON COUNTY PUBLIC HEALTH �w �i The undersigned approves this Installation Report and n �`� �� Record Drawing on behalf of Mason County Public • t�'z•�►ICAHT c ON'4' L►CEtSED DESIGNER Health: II J/l I EXPIRES:t?911dF Signature of Environmental Health Specialist Date (stamp, signature and date) THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 8/21r2018 s R 10-, � / N N NI c N / 3 N 3 N cD N - � 3 N N (O N Q.. 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