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HomeMy WebLinkAboutSWG2021-00053 - SWG As-Built - 1/27/2023 C-f 9 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH • APPLICANT/ PERMIT INFORMATION Permit Number SWG 2021-00053 Parcel # 42209-51-00109 Applicant Name DAVID KLOCK Subdivision (Name/Div/Block/Lot) Applicant Address 16311 96TH AVE CT E City, State, Zip PUYALLUP, WA. 98375 Installer Name T J EXCAVATING Site Address 510 N FAIRWAY DR W Designer Name CINDY WAITE INSTALLATION CHECKLIST i Full System Installation ❑ Tank(s)Only ❑ Drainfield Only ❑ Repair p ❑Other System Type GRAVITY _,,`- .P treatment Type >5 ft. from foundation? - f%1;_ 11-�- >50 ft. from wells? - 1 (C� ❑ N/A YES ❑ NO surface water? - \ _ 4� El ❑Z >50 ft. from \ - H Cleanout between building and tank? - - .` �r - ❑ I ❑ U Tank baffles present? - 1 _ ❑ 0 ❑ a24"access risers over each compartment?- t�-�' - ❑ 0 ❑ W Effluent filter installed?- ❑ Iii ❑ cn ❑ 0 ❑ Septic tank size 1300 gal Manufacturer PREMIER 5 D-box water level and speed levelers used? ❑ N/A © YES ❑ NO 0u. Manifold/D box accessible from surface?- - ❑ mZ Check valves installed? - NE ID ❑Q - ❑ ❑ 0 E Transport Line Size 4 Schedule/Class 3034 Bedrooms installed (check one)) ❑ 20 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other >10 ft. from foundation?- - >100 ft. from wells?- ❑ N/A • YES ❑ NO --I >100 ft. from surface water? - w ❑ 0 ❑ ti >10 ft. from potable water lines?- El 0 ❑ Z - Q > 5 ft. from property lines and easements?- - ❑ II ce > 30 ft. from downgradient curtain/foundation drains? - - RI ❑ ca Drainfield level and observation ports present - - ❑ ❑ IR ❑ 0 Graveless chambers or ElClean gravel used? (check one) Proper cover installed over drainfield?- _ ❑ 0 CI Pump tank setbacks consistant with se isS . �� t;' - ❑ N/A ❑ YES ® NO Y Pump tank size • , ,, I Manuf- •A'r Z 24" access riser(s) and ac ", is e from s Z3- _ Q. Alarm or Control Panel In-:'.-, •? - , � eLSH ❑ ❑ ❑ Control Panel equipped � ON����� - ❑ ❑ ❑ wi ' A� eL� yl �unier - ❑ ❑ ❑ _0. Pump installed in ❑ Bucl c or El Or ck or ❑ Other a Pump Make/Model ❑ Floats or El Transducer V M Tank draw down a in/min Pump capacity gpm Squirt Height ft Pump on time Pump off time Daily flow set at gpd Jpdated 8/21/2018 • Mason County OSS Installation Report pg. 2 Parcel# 42209-51-00109 ABANDONMENT RECORD Were existing septic components abandoned as part of this project'? - -_ -If yes, please describe: ❑ YES 0 NO Were all components pumped out and properly abandoned per WAC246-272A-0300? - ❑ YES 0 NO RECORD DRAWING This is a pennanent record and must be accurate and descriptive enough to re-locate in the need of maintenance activities and future development. Typical Record Drawings contain' Draintield&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. rPRovE { JAN 21 2023 04k0-JN COUNTY ENVIRONMENTAL HEALTH JBW ® 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 certify that all information contained on this I further certify that all information contained on this form and attached Re ord Drawing is accurate. form and attached Record Dr.wing is accurate. .-3 Signature of Installer Date?,' AO I i i Printed Name of Signee ,,� i zc 1 (iV im 7 '° j1,+ li MASON COUNTY PUBLIC HEALTH o ;48 ` The undersigned approves this Installation Report and O DY DESIGNER E tr��`11 Record Drawing on behalf of Mason CountyPublic .' ENSE DESIGNER o Healt EXPIRES USilOi f Sign tur:nrEnvironmental Health Specialist Date (stamp, signature and date) THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE updated8;2'i20f8 i 1, Pn dporea es 1 O1c,e__ S!a N al.z.rw ( Pi/ 1-12 6 ?- 67- Gp 10q 3. c(e4N414.1 Y f 3o v c ai'UA/ Ptte S- D— Boo( w/ spect vttir 77- �R'+ese /t✓a Qtel , r`" ( LCrH/S'p0 (ewe j oQ. die.? (rive v � M NO / . . �P ' :sSO 9 1\� �JD Cu A J � N ' ab �� ll '. . rim AITE ,F; O i �� E SI ER F,__,= ,,._.,,..............._ ,.......-- _......_ . i A ji,, 4 S, , t. 1 -C--- -----.- 'j .._____,.......... . ... ,-APPROVE4-1.- 1\ i (ii.D, 0 i (. .i `‘t . JAN 2 l 2013 nw it er hvt)'y' Iv1ASON COUNTY ENVIRONMENTAL HEALTH JBW @ 0-.40 ''. 5,i4' 2 Ci ' i Le(// Al U 4 i'.iJ4.14194e 6 v�____i ��� 0- (f'i 6 / " - Z v' /Ale a r`44,44,04